Vet Wellness Center Green - Employment Application Form

1
Name
Date
Position Desired
Minimum Salary
How did you learn about us?
Ever applied here before?
Telephone Number
Alternate Number
2
Email
example@example.com
3
Are you a citizen of the U.S.?
Yes
No
4
If not, do you have legal right to work in the U.S.?
Yes
No
5
Do you speak or read any languages fluently besides English?
Yes
No
6
If yes, which one(s)
7
Are you 18 years of age or older?
Yes
No
8
If not, please specify age
9
Have you ever been convicted of a felony crime?
Yes
No
10
Are there any criminal charges pending against you?
Yes
No
11
Signature* This field is required.Background testing is an employment requirement. I understand that if I am offered a position, a background test will be required.
Clear
12
Signature* This field is required.Drug- Free Screening is an employment requirement. I understand that if I am offered a position, drug screening will be required prior to my employment.
Clear
13
Education
High School
College / University
Graduate School
Trade School
Name of School
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
City / Sate
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Degree / Major
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Name of School
City / Sate
Degree / Major
High School
Row 0, Column 0
College / University
Row 0, Column 1
Graduate School
Row 0, Column 2
Trade School
Row 0, Column 3
High School
Row 1, Column 0
College / University
Row 1, Column 1
Graduate School
Row 1, Column 2
Trade School
Row 1, Column 3
High School
Row 2, Column 0
College / University
Row 2, Column 1
Graduate School
Row 2, Column 2
Trade School
Row 2, Column 3
1 of 3
14
Employment History
Employment Dates
Employers Name & Address
Position / Job Duties
Reason for leaving
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
1
2
3
Employment Dates
Row 0, Column 0
Employers Name & Address
Row 0, Column 1
Position / Job Duties
Row 0, Column 2
Reason for leaving
Row 0, Column 3
Employment Dates
Row 1, Column 0
Employers Name & Address
Row 1, Column 1
Position / Job Duties
Row 1, Column 2
Reason for leaving
Row 1, Column 3
Employment Dates
Row 2, Column 0
Employers Name & Address
Row 2, Column 1
Position / Job Duties
Row 2, Column 2
Reason for leaving
Row 2, Column 3
1 of 3
15
Is any information relative to change in name, use of an assumed name, or nickname necessary to check your work record or background information?
Yes
No
16
If yes, please provide other names
17
Authorized signature* This field is required.
Clear
18
Date* This field is required.
Date
Year
Month
Day
19
Is there anything else you would like us to know about you?
20
Applicant’s Affidavit

I certify that the information contained in this application is correct to the best of my knowledge. I authorize investigation of all maters contained in this application and agree that any misleading or false statements would be cause for rejection of this application or would be sufficient cause for dismissal after employment begins. I understand that employment is contingent upon the receipt of negative drug screening results, background check, and satisfactory work references by HOSPITAL NAME. I further understand that my continued employment will be based on my satisfactory performance and the satisfactory completion of Benefits Waiting period of employment.
21
Signature* This field is required.
Clear
22
Date* This field is required.
Date
Year
Month
Day
Should be Empty:

Applicant’s Affidavit