Khit Chiropractic Job Application

The application must be completed in full to be considered for employment.

Name*

Date*

Date

Clinic/Department you are interested in working for:*

If under 18, please list age

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How long have you lived at this address?*

Position applied for:*

Are you a US Citizen?*

YesNo

If no, are you authorized to work in the US?

YesNo

Have you applied here before?*

YesNo

If yes, when?

Have you ever worked for this company?*

YesNo

If yes, when and where?

Desired Salary:*

How many hours can you work weekly?*

Can you work weekends if necessary?*

YesNo

Can you work nights if necessary?*

YesNo

Employment desired:*

Full-time onlyPart-time onlyFull or part-time

When are you available to start if hired:*

Date

Days available to work:*

Hours available to work:*

No preferenceDaysNights

Are you able to perform the essential job functions of the position for which you are applying with or without reasonable accommodation?*

YesNo

Are you related in any way to anyone working at Khit Chiropractic or any of its affiliated entities?*

YesNo

If yes, who?

Are you willing to wear a uniform if required for the position you are applying for?*

YesNo

Are you currently licensed Doctor of Chiropractic in Texas?*

YesNo

Are you currently licensed in Texas as a Licensed Massage Therapist (LMT) or Chiropractic Assistant (CA)?*

YesNo

Are you willing to go to other company locations in the area as needed to meet company needs?*

YesNo

Are you willing to travel to other company locations not within normal commuting distance (more than two hours)?*

YesNo

Have you ever been convicted of a crime?*

YesNo

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

High School

College/University

Business or Trade School

Professional School

Other education, training, or certifications

Please check if you have experience with any of the following (check all that apply):*

Languages spoken and level of fluency:*

Reference

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

Have you served in the Armed Forces?*

YesNo

Branch:

Are you now a member of the national guard or reserve component?*

YesNo

Specialty:

Dates of service

Type of separation

Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name.

Employer #1

Employment dates:*

Reason for leaving (be specific):*

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.*

Employer #2

Employment dates:*

Reason for leaving (be specific):*

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.*

Employer #3

Employment dates:

Reason for leaving (be specific):

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Employer #4

Employment dates:

Reason for leaving (be specific):

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

May we contact your present employer?*

YesNo

Did you complete this application yourself?*

YesNo

If not, who completed it for you?

What special skills or training do you have that would make you stand out?*

Why should we hire you?*

What is the ideal work environment? What brings out your best performance?*

What does customer service mean to you?*

Job Specific questions for DC and CA applicants:

What does health mean to you and why is it important to clients/patients?

What continuing education do you plan on taking to further your skills?

Name*

Former name(s) if any:

Dates used:*

Previous Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Driver's License Number or ID/State:*

Social Security Number*

Date of Birth: (Month/Day/Year)*

Date

Telephone Number*

The information contained in this application is correct to the best of my knowledge. In exchange for the consideration of my job application by Khit and Associates (hereinafter called "the Company"), I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment or to confer any right to remain an employee of Khit and Associates, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President/General Manager of the Company. Both the undersigned and Khit and Associates may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise its benefits, policies, and procedures and such changes may include a reduction in benefits. I authorize the investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others and hereby release the Company from any liability as a result of such contract.

I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical

I hereby authorize Khit and Associates and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records. I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to Khit and Associates or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. Khit and Associates and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicants personal information, including, but not limited to, addresses, social security numbers, and dates of birth.

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature of applicant*

Date*

Date

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age, or disability. We assure you that your opportunity for employment with Khit Chiropractic & Wellness Center depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.

Khit Chiropractic Job Application 03-2021

Education

General Skills

Personal References

Work History and Military Duty

Questionnaire

Background Check Authorization: