UP Application wo SSN

To the applicant: We appreciate your interest in our Agency and assure you that we are interested in your qualifications. A clear understanding of your background and work history will aid us in seeking to place you in a position which, in our judgment, best meets your qualifications.

We are an equal opportunity employer and will not unlawfully discriminate on the basis of race, color, sex, religion, national origin, age, height, weight, marital, familial or veteran status, arrest record or the presence of a medical condition or disability.

DATE*

Date

Name*

First NameMiddle NameLast Name

Maiden

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Telephone*

Email Address*

example@example.com

Do you know anyone that works for University Pediatricians and/or University Pediatricians Autism Centers?*

YesNo

Name

Relationship to Applicant

Are you 18 years old or older?*

YESNO

If "NO", can you provide proof of your eligibility to work?

YESNO

Are you currently authorized to work in the United States?*

YESNO

Position applied for*

Wage desired*

Days/hours available to work*

	Hours
No Pref
Mon
Tue
Wed
Thur
Fri
Sat

Employment desired*

FULL-TIME ONLYPART-TIME ONLYFULL-OR-PART-TIME ONLYCONTINGENT

When are you available to start work?*

Date

Education*

	Name of School	Location	Number of Years Completed	Degree Awarded and Major
High School
College
Bus. or Trade School
Professional School

Computer proficiency*

EMR programsBilling programsOffice 365Other

Other skills*

Please list two business references (one reference must be a current or previous supervisor)

Reference 1:

Name*

Position*

Company*

Address*

Email*

example@example.com

Telephone*

Reference 2:

Name*

Position*

Company*

Address*

Email*

example@example.com

Telephone*

Please enter a valid phone number.

Please use the space to elaborate on any background, experience, or qualifications that you believe should be considered in evaluating your qualifications for employment. You may include hobbies, volunteer experience and any other activities you believe relevant. Please omit any information that would disclose your race, gender, age, marital status, ethnic origin, religious or political affiliations, or disability.*

Are you a veteran of the U.S. Armed Forces?*

YesNo

ARE YOU NOW A MEMBER OF THE NATIONAL GUARD?

YesNo

Date Entered

Date

Discharge Date

Date

Employee Name*

First NameLast Name

Name of employer

Job Title

Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

May we contact this employer?

YesNo

Reason for leaving (be specific)

Name of last supervisor, phone number, and email:

Employment dates (month/year)

Name of employer:

Job Title

Address

Street Address

Street Address Line 2

CityState

Zip Code

Employer Phone Number

Please enter a valid phone number.

Name of last supervisor, phone number and email

Employment dates (month/year)

May we contact this employer?

YesNo

Reason for leaving (be specific)

Name of employer

Phone Number

Please enter a valid phone number.

Job Title

Address

Street Address

Street Address Line 2

CityState

Zip Code

Name of last supervisor, phone number, and email:

Reason for leaving (be specific)

May we contact this employer?

YesNo

Employment dates

In exchange for the consideration of my job application by University Pediatricians, (hereinafter called "the Company"), 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 conferany right to remain an employee University Pediatricians, or otherwise to change in any respect the employment-at-wi relationship between it and the undersigned, and that relationship cannot be altered except by written instrument signed by the Owner/Managing Member of the Company. Both the undersigned and University Pediatricians may end the employment relationship at any time, without specified notice or reason. If employed, understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

- authorize investigation of all statements contained in this application. understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. hereby give the Company permission to contact schools, all previous employers (unless otherwise indicated), references and others and hereby release the Company from any liability as a result of such contact.

As an applicant for employment or a current employee of University Pediatricians, you are a consumer with rights under the Fair Credit Reporting Act. When any of the following circumstances exist, University Pediatricians may choose to obtain and use information contained in eithera consumer report or an investigative consumer report from a consumer reporting agency about you when: 1) considering your applicationfor employment, 2) making a decision whether to offer you employment 3) deciding whether to continue your employment of you are hired), or4) making other employment-relatec decisions directly affecting you. For explanation purposes, a "consumer reporting agency" is a person or business which, for monetary fees, dues, or on a cooperative non-profit basis, regularly assembles or evaluates consumer credit information or other information on consumers for the purpose of furnishing consumer reports to others, such as University Pediatricians. A "consumer report" means any written, oral, or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing. credit capacity. character, general reputation personal characteristics, or mode of living. which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing your eligibility for employment purposes. An"Investigative consumer report" means a consumer report or portion thereof in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your neighbors, friends, or associates reported on or with others with whom you are acquainted or who may have knowledge concerning any such items of information In the event an investigative consumer report is prepared, you may request additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act. By signing below, hereby voluntarily authorize University Pediatricians to obtain either a consumer report or an investigative consumer report about me from a consumer reporting agency and to consider this information when making decisions regarding my employment at University Pediatricians. understand that have rights under the Fair Credit Reporting Act, including the rights discussed above.

Bysigning below, hereby authorize University Pediatricians to investigate of all statements contained in my application. - also authorize the investigation of all references andiormer employers containedin myapplication and the release of all information (which can be legally provided) concerning my prior employment, education and qualifications for employment. - understand that, under Michigan law only, if need a reasonable accommodation for a disability in order to perform the essential functions of my position or the position seek, I must request the accommodation in writing within 182 days of the day knew or should have known of the need.

Talso agree that any action or suit against University Pediatricians, or its owners, officers, directors or employees, arising out of my employment or termination of employment, including. but not limited to, claims arising under state or federal civil rights statutes, must be brought within180 days of the event giving rise to the claim or be forever barred. This applies to the initial charge filed with the Equal Employment Opportunity Commission: however thereafter am permitted to pursue litigation as provided in the Commission's "Right to Sue" letter. - walve any longer,but not shorter, limitations periods to the contrary.

I CERTIFY THAT THE INFORMATION GIVEN ON THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE.

IUNDERSTAND THAT FALSIFICATION OF INFORMATION REQUESTED ON THIS APPLICATION is GROUNDS

Signature of applicant*

Date*

Date

University Pediatricians

MILITARY

APPLICATION FOR EMPLOYMENT