Employment Application

Foot & Ankle Physicians of Ohio is an equal opportunity employer and affords equal opportunity to all applicants for all positions without regard to race, color, religion, gender, national origin, age, disability, veteran status or any other status protected under local, state or federal laws.

Position(s) Applied For

Date of Application

Date

Name*

First NameMiddle NameLast Name

Address

Street Address Line 2

CityState

Zip Code

Telephone Number*

Please enter a valid phone number.

Email Address*

example@example.com

Social Security Number (If available)

How Did You Hear About Us?

Newspaper AdEmployment AgencyCurrent EmployeeOther

If Current Employee, please name:

Other

Are you legally eligible to work in the United States? (Proof of eligibility will be required upon offer of employment)

YesNo

Are you over the age of 18 years? (If no, you may be required to provide authorization)

YesNo

Can you with or without reasonable accommodation perform the essential functions of this job? (If you have any questions about the functions of the job, please ask the interviewer before answering this question)

YesNo

Have you ever applied to Foot & Ankle Physicians of Ohio before? (If yes, please give date.)

YesNo

If "Yes," please give date:

Date

Have you ever worked for Foot & Ankle Physicians of Ohio before?

YesNo

If "Yes," please give date:

Date

If yes, please explain

Do you have a valid driver's license? (For driving positions only)

YesNo

Have you been convicted of any moving violations in the past five years? If yes, please explain: Is anyone related to you employed by Foot & Ankle Physicians of Ohio?

YesNo

If yes, please explain

Is anyone related to you employed by Foot & Ankle Physicians of Ohio?

YesNo

If yes, please give their name and relationship to you.

What salary or rate of pay do you expect to receive if employed?

Per

Have you ever been fired or asked to resign from a job?

YesNo

If yes, please explain:

On what date would you be available to work?

Date

Days and Hours Available: (If employed, I will notify my supervisor in writing, should my availability change.)

	Monday	Tuesday	Wednesday	Thursday	Friday
AM
PM

EDUCATION

Elementary School - Name and Location

Elementary School - # of Years Completed

Elementary School - Diploma/Degree

High School - Name and Location

High School - # of Years Completed

High School - Diploma/Degree

College - Name and Location

College - Course of Study or Major

College - # of Years Completed

College - Diploma/Degree

Graduate - Name and Location

Graduate - Course of Study or Major

Graduate - # of Years Completed

Graduate - Diploma/Degree

Vocational - Name and Location

Vocational - Course of Study or Major

Vocational - # of Years Completed

Vocational - Diploma/Degree

Please list any academic honors, scholarships, offices held, etc. (Do not list any which reflect your race, color, religion, gender, national origin, age, disabilities or veteran status)

Describe any specialized training, apprenticeships, licenses or skills.

Have you received any job-related training in the United States Military?

YesNo

Please give dates and explanation:

EMPLOYMENT HISTORY (Begin with current or most recent employer Do not exclude any employment. Include any applicable temporary employment - attach another sheet if necessary. Previous salaries or wages will not be used to determine compensation at Foot & Ankle Physicians of Ohio.

Company Name

Employment Dates

From:

Date

To:

Date

Salary (Start)

Salary (End)

Name and Title of Supervisor

Address

Phone

Describe your duties

Reason for leaving and explanation

Company Name

Employment Dates

From:

Date

To:

Date

Salary (Start)

Salary (End)

Name and Title of Supervisor

Address

Phone

Describe your duties

Reason for leaving and explanation

Company Name

Employment Dates

From:

Date

To:

Date

Salary (Start)

Salary (End)

Name and Title of Supervisor

Address

Phone

Describe your duties

Reason for leaving and explanation

Please provide any other information that you feel will help us in considering your application for employment.

REFERENCES (Please list three persons, who are not related to you or previous supervisors, who can provide professional references.)

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Relationship/Occupation

Years Known:

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Relationship/Occupation

Years known:

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Relationship/Occupation

Years known:

APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION

*PLEASE READ CAREFULLY BEFORE SIGNING*

I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by Foot & Ankle Physicians of Ohio that such employment with Foot & Ankle Physicians of Ohio is at will, for no specified duration and may be terminated by either] or Foot & Ankle Physicians of Ohio myself at any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions, statements of Foot & Ankle Physicians of Ohio or its representatives used during the employment process is deemed a contract of employment real or implied. I understand that no representative of Foot & Ankle Physicians of Ohio except the President has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the President of Foot & Ankle Physicians of Ohio.

In consideration for employment with Foot & Ankle Physicians of Ohio, if employed, I agree to conform to the rules, regulations, policies and procedures of Foot & Ankle Physicians of Ohio at all times and understand that such obedience is a condition of employment. I understand that due to the nature of Foot & Ankle Physicians of Ohio business, attendance and punctuality are considered essential requirements of every jobat Foot & Ankle Physicians of Ohio and that poor attendance or tardiness will result in disciplinary action.

I understand that if offered a position with Foot & Ankle Physicians of Ohio, I may be required to submit to a pre-employment medical examination, drug screening and background check as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employments tests and checks will result in withdrawal of any employment offer or termination of employment if already employed.

I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to Foot & Ankle Physicians of Ohio and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information.

I understand that this application is considered current for three months. If I wish to be considered for employment after this period I must fill out and submit a new application.

BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS.

Signature*

Date

Name and number of person completing this form if other than applicant:*

FOOT & ANKLE PHYSICIANS OF OHIO IS PROUD TO BE AN EQUAL OPPORTUNITY EMPLOYER. ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, AGE, DISABILITY, VETERAN STATUS OR ANY OTHER STATUS PROTECTED BY LAW.