Employment Application

Employment Application

Personal Information
All applicants are considered for all positions without regard to race, religion, color, sex, gender, sexual orientation, pregnancy, age, national origin, ancestry, physical/mental disability, medical condition, military/veteran status, genetic information, marital status, ethnicity, citizenship or immigration status, or any other protected classification, in accordance with applicable federal, state, and local laws. By completing this application, you are seeking to join a team of hardworking professionals dedicated to consistently delivering outstanding service to our patients and contributing to the success of the organization, and its employees. Equal access to programs, services, and employment is available to all qualified persons. Those applicants requiring an accommodation to complete the application and/or interview process should contact a management representative.
First Name*
Last Name*
Middle Name
Date of Birth*

MonthDayYear
Current Date

MonthDayYear
You must be over 18 to apply!
Current Age (You must be over 18 to apply)
Email*
example@example.com
Address Line 1*
Address Line 2
Apartment/Unit#
City*
State*
ZIP Code*
Phone Number*
Please enter a valid phone number.
Social Security Number*
Please enter your SSN.

Reference Information

Please list at least one professional reference
Reference 1 Full Name*
Reference 1 Relationship*
Reference 1 Phone*
Reference 1 Address
Reference 2 Full Name
Reference 2 Relationship
Reference 2 Phone
Reference 2 Address

Previous Employment

Please list the names of your last two employers in chronological order with present or most recent employer listed first.
Have you ever been involuntarily terminated or asked to resign from ANY job?*

YesNo
If yes, please explain:*
Click here if you have no recent employer or if you are returning from unemployment
Most Recent Employer 1/2
Company Name*
Phone Number*
Address
Supervisor Name
Job Title*
Starting Salary
Ending Salary
Recent Employer Company 1 Responsibilities*
Recent Employer Company 1 From Date*

MonthDayYear
Recent Employer Company 1 To Date*

MonthDayYear
Recent Employer Company 1 Reason For Leaving*
Do you authorize us to contact this reference?*

YesNo
Most Recent Employer 2/2
Company Name
Phone Number
Address
Supervisor Name
Job Title
Starting Salary
Ending Salary
Recent Employer Company 2 Responsibilities
Recent Employer Company 2 From Date

MonthDayYear
Recent Employer Company 2 To Date

MonthDayYear
Recent Employer Company 2 Reason For Leaving
Do you authorize us to contact this reference?

YesNo

DISCLAIMER AND SIGNATURE
Please read and initial each paragraph below. If there is anything that you do not understand, please ask.
I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for
employment and, further, authorize the prior employers and references I have listed to disclose to the company any and all letters, reports, and other
information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former
employers, and all other persons, corporations, partnerships, and associations from any and all claims, demands, or liabilities arising out of or in any
way related to such investigation or disclosure.

In the event of my employment with the company, I understand that I am required to comply with all rules and regulations of the company.

If hired, I understand and agree that my employment with the company is at will and that neither the company nor I am required to continue the
employment relationship for any specific term. I further understand that the company or I may terminate the employment relationship at any time,
with or without cause, and with or without notice. I understand that the at-will status of my employment cannot be amended, modified, or altered in
any way by any oral modifications.

I understand that the safety of employees is extremely important to the company and that the company is committed to ensuring a safe working
environment. I understand that I, and every employee, have a responsibility to prevent accidents and injuries by observing all safety procedures and guidelines and following the directions of my site supervisor. I understand and agree to comply with federal, state, and local regulations related to on-
the-job safety and health.

I hereby certify that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time
elapsed before discovery.

I understand that if I am selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the
United States, and that federal immigration law requires me to complete an I-9 Form in this regard.

I understand that if any term, provision, or portion of this Agreement is declared void or unenforceable, it shall be severed, and the remainder of this Agreement shall be enforceable.

My signature attests to the fact that I have read, understand, and agree to all of the above terms.
First Name
Last Name
Signature*

Clear
Should be Empty:

Employment Application

You must be over 18 to apply!

Employment Application

Reference Information

Previous Employment

Most Recent Employer 1/2

Most Recent Employer 2/2

DISCLAIMER AND SIGNATURE