Employment Application for PMI

Position(s) Sought

Date of Application

Date

Department/Physician Office Location (if known)

Full-Time Part-Time

Available Start Date

Date

Referral Source

Advertisement Friend Relative Walk-In Employment Agency

Online Employment Website

Other (Specify)

Name

First Name Middle Name/Initial Last Name

Address

Street Address Line 2

City State

Zip Code

Email Address

example@example.com

Home

Cell

Driver’s License Number

Social Security Number: (for Background Check Only)

Do you have current and unrestricted authorization to work in the United States?

Yes No

Have you previously applied here?

Yes No

If Yes, give date

Date

Are you 18 years of age or older?

Yes No

Have you been employed here before?

Yes No

Have you been employed here before? If Yes, give date/position:

Position:

Do you have relatives working here?

Yes No

If Yes, give name:

Additional Relative:

Are you currently on layoff?

Yes No

If Yes, are you subject to recall?

Yes No

Have you been convicted of a felony within the last 7 (seven) years?

Yes No

If Yes, explain/give details below

Identify any potential Conflicts of Interest you may have if employed here: (ex. Family relationships, ownership in medical provider business, employment with entity supplying goods or services to PHO Network)

LANGUAGES YOU SPEAK, READ AND/OR WRITE

	FLUENT	SATISFACTORY	FAIR
SPEAK
READ
WRITE

Completed

	High School	Undergraduate	Graduate
School Name
Number of Years
Diploma/Degree
Describe Course of Study
Describe Specialized Training, Apprenticeship, Skills, or Other Job Related Activities
Honor(s) Received

Begin with your most recent employment. Include military assignments. (You may exclude those that indicate race, color, religion, sex, sexual preference or national origin)

Employer

Full Address

Telephone

Supervisor

May We Contact this Employer?

Yes No

Employment Start Date

Date

Employment End Date

Starting Rate of Pay

Ending Rate of Pay

Job Title

Worked Performed

Reason for Leaving

Employer

Full Address

Telephone

Supervisor

May We Contact this Employer?

Yes No

Employment Start Date

Date

Employment End Date

Date

Starting Rate of Pay

Ending Rate of Pay

Job Title

Worked Performed

Reason for Leaving

Employer

Full Address

Telephone

Supervisor

May We Contact this Employer?

Yes No

Employment Start Date

Date

Employment End Date

Date

Starting Rate of Pay

Ending Rate of Pay

Job Title

Worked Performed

Reason for Leaving

Special Skills and Qualifications (include Software Programs)

List Professional, Trade, Business or Civic Activities and Offices Held. (You may exclude those which indicate race, color, religion, sex, sexual preference or national origin)

Name

Dates

State Any Additional Information You Feel May be Useful in Considering Your Application

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

I authorize investigation into all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract of employment.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in corrective action up to and including termination. I understand that I am required to abide by all rules, policies and regulations of the company.

I understand that, if I am hired, my employment is at-will, that I am not employed for any definite term, that I may be terminated at any time, with or without cause or advance notice. I understand that the Organization retains the right to unilaterally modify, revise, add to, or delete from its employment policies and that I will be given reasonable notice of such changes via e-mail. I further understand that I am responsible for reading and understanding all policies including new or revised policies and procedures to the Human Resource Manual when notice has been received.

Signature of Applicant

Date

Genesys PHO and Providers Management, Inc. are Equal Opportunity Employers. In adherence to applicable state, federal and local laws, all employees and applicants will be treated in employment practices without regard to race, color, religion, age, sex, sexual preference, national origin, disability, or veteran status.

EMPLOYMENT APPLICATION

Telephone Numbers:

EDUCATION

EMPLOYMENT/EXPERIENCE

Dates Employed:

Dates Employed:

Dates Employed:

If You Need Additional Space, Continue On a Separate Sheet

APPLICANT’S STATEMENT

EQUAL OPPORTUNITY STATEMENT