Job Application Form

Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Current Address*

Street Address

Street Address Line 2

CityState

Postcode
Email Address*
Phone Number*
Position Applying For
Pick one
Desired start date

DayMonthYear
Desired Salary

Previous employment Please use this section to provide information about your previous employment starting with your current or most recent job.
Employment details

CompanySupervisorPhone NumberJob title
Company Address

Street Address

Street Address Line 2

CityState

Postcode
Employment start date

MonthDayYear
Employment end date, if current us future date

MonthDayYear
Responsibilities
Reason for leaving / interest in leaving
Employment details - most recent

CompanySupervisorPhone NumberJob title
Company Address

Street Address

Street Address Line 2

CityState

Postcode
Employment start date

MonthDayYear
Employment end date if still employed us a future date

MonthDayYear
Responsibilities
Reason for leaving

Education Please use this section to provide information about your previous education including the qualifications/certificates your have gained.
Medical Certificate School

School nameStart dateFinish date
State and County
Subjects Studied
High School / College

School nameStart dateFinish date
State and County
Subjects Studied
Other

School nameStart dateFinish date
State and County
Subjects Studied

Refrences Please use this section to provide a list of three professional references.
Reference 1

Full nameRelationshipPhone number
Reference 2

Full nameRelationshipPhone number

Federal law requires that employers hire only individuals who are authorized to be lawfully employed in the United States. In compliance with these laws, Bruce S West MD will verify the status of every individual offered employment with the office. In this connection, all offers of employment are subject to verification of the applicant’s identity and employment authorization, and it will be necessary for you to submit such documents as are required by law to verify your identification and employment authorization.
PLEASE READ CAREFULLY BEFORE SUBMITTING APPLICATION

I have submitted the attached form to the company for the purpose of obtaining employment. I acknowledge that the use of this form, and my filling it out, does not indicate that any positions are open, not does it obligate the company to further process my application.

My submittal attests to the fact that the information that I have provided on my application, resume, given verbally, or provided in any other materials, is true and complete to the best of my knowledge and also constitutes authority to verify any and all information submitted on this application. I understand that any misrepresentation or omission of any fact in my application, resume or any other materials, or during any interviews, can be justification for refusal of employment, or, if employed, termination from Bruce S. West MD's employ.

I also affirm that I have not submitted any kind of restrictive document creating any obligation to any former employer that would restrict my acceptance of employment with Bruce S. West MD in the position I am seeking.

I understand that this application is not an employment contract for any specific length of time between the Bruce S. West MD's and me, and that in the event I am hired, my employment will be “at will” and either Bruce S. West MD or I can terminate my employment with or without cause and with or without notice at any time. Nothing contained in any handbook, manual, policy and the like, distributed by Bruce S. West MD's to his employees is intended to or can create an employment contract, an offer of employment or any obligation on his part.Bruce S. West MD may, at its sole discretion, hold in abeyance or revoke, amend or modify, abridge or change any benefit, policy practice, condition or process affecting its employees.

References: I hereby authorize Bruce S. West MD and its agents to make such investigations and inquiries into my employment and educational history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, and other persons from all liability in responding to inquires connected with my application and I specifically authorize the release of information by any schools, businesses, individuals, services or other entities listed by me in this form. Furthermore, I authorize Bruce S. West MD and its agents to release any reference information to clients who request such information for purposes of evaluating my credentials and qualifications.

Temporary/Contract Employment: If employed as a temporary or contract employee, I understand that I may be an employee ofBruce S. West MD and not of any client. If employed, I further understand that my employment is not guaranteed for any specific time and may be terminated at any time for any reason.
Signature*

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By signing I agree to terms and submission information.
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