Employment Application Form

Employment Application Form
Please complete the following information
Applying for*
An Equal Opportunity Employer
Please Define
Identification
Name*

First NameMiddle NameLast Name
Home Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address *
Drivers License Number
State of issue
Work schedule availability
Days available to Work:*

SundayMondayTuesdayWednesdayThursdayFridaySaturday
Time Available to Work:*
Available to Work*
Available to Work*
Date You Can Begin Work*

MonthDayYear
Date
Employee history

The Drug Enforcement Agency requires us to ask these questions of every applicant
Have you been convicted of a felony or misdemeanor? (Do not include any traffic violations or juvenile offenses)*

YesNo
If the answer is yes, furnish details of conviction, offense, location, date and sentence.
Have you ever knowingly use any narcotics, amphetamines or barbiturates, other than those prescribed to you by a physician?*

YesNo
If the answer is yes, furnish Details.
Education / Training history

List colleges, military, trade, business or other schools attended
Do you have a high school diploma or a GED certificate*

YesNo
Name and Location of School, College or University
Course of Study (List Major)
Credits Earned
Did you Graduate?*

YesNo
Degree or certificate received
Add More Qualification?*

YesNo
Name and Location of School, College or University
Course of Study (List Major)
Credits Earned
Degree or certificate received
License / Registration / Certificate

List any required professional license, registration, certificate, Commercial Drivers License, etc.

	Description	State	Number	Expiration
1
2
3

Specialized Skills and Knowledge*
List skills or knowledge that show your ability to perform the job for which you are applying (such as typing speed, computer skills, foreign languages etc.).
Work History

Current or Most Recent Position
Name of Employer
Employer’s address and phone number
Type of business
Supervisor’s name and phone number
Your job title
From (Month / Year)
To (Month / Year)
Total time in current or last position
Hours worked per week (average)
Supervision / leadership check areas you were responsible for:*

Assigning and Reviewing WorkHandling Disciplinary problemsRating Work PerformanceResponding to GrievancesHiring or Recommend HiringNot Responsible for Any of the Above
List the number of employees and job titles
Duties (List all duties you performed. No credit will be given if this section is not completed)*
Reason for leaving
Employer Type*
May we contact?*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add More job?*

YesNo
Job number 2
Name of Employer
Employer’s address and phone number
Type of business
Supervisor’s name and phone number
Your job title
From (Month / Year)
To (Month / Year)
Total time in current or last position
Hours worked per week (average)
Supervision / leadership check areas you were responsible for:

Assigning and Reviewing WorkHandling Disciplinary problemsRating Work PerformanceResponding to GrievancesHiring or Recommend HiringNot Responsible for Any of the Above
List the number of employees and job titles
Duties (List all duties you performed. No credit will be given if this section is not completed)
Reason for leaving
Employer type
May we contact?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add More job?*

YesNo
Job number 3
Name of Employer
Employer’s address and phone number
Type of business
Supervisor’s name and phone number
Your job title
From (Month / Year)
To (Month / Year)
Total time in current or last position
Hours worked per week (average)
Supervision / leadership check areas you were responsible for:

Assigning and Reviewing WorkHandling Disciplinary problemsRating Work PerformanceResponding to GrievancesHiring or Recommend HiringNot Responsible for Any of the Above
List the number of employees and job titles
Duties (List all duties you performed. No credit will be given if this section is not completed)
Reason for leaving
Employer type
May we contact?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Certification and signature

I understand that any verbal or written statement that is false, fraudulent or misleading that is contained in this application or attached materials, or made in the course of any related employment process, whether made by me or by others at my request, will result in rejection of my application, denial of employment, or dismissal from service if discovered after employment, and under some circumstances, may result in prosecution for a crime. This authorization is valid for purposes of verifying information given in connection with my application for employment covered under the Equal Opportunity Act (EEOA), Fair Credit Reporting Act (FCRA) and the Drivers Privacy Protection Act (DPPA). In addition, I understand that Woodland Springs Veterinary Hospital may conduct additional background checks during my employment if I am hired. This authorization shall be valid in original or facsimile form. You may contact me personally if you need to further verify and authenticate this request.
I certify that all statements contained herein are true and complete.I understand that if hired, I must prove that I am legally authorized to work in the United States.I authorize Woodland Springs Veterinary Hospital to check employment references and verify education information provided on this employment application and as disclosed in the interview process.I authorize Woodland Springs Veterinary Hospital to check my driving record if the position for which I am applying requires driving.I authorize Woodland Springs Veterinary Hospital to run a consumer credit report, criminal history background check, and/or drug test as a condition of employment.I release Woodland Springs Veterinary Hospital and all providers of information from any liability as a result of furnishing and receiving any information related to the hiring process.I authorize all corporations, former employers, supervisors, credit agencies, educational institutions, law enforcement agencies, city, state, county and federal courts and agencies, military services and other persons or entities with relevant information about me to release any and all such information only to Woodland Springs Veterinary Hospital and their representatives.
Full Name*
Date*

MonthDayYear
Date of Birth*

MonthDayYear
Applicant’s signature*

Clear
Other names used (maiden, nickname, etc.)
Should be Empty:

Employment Application Form

Identification

Work schedule availability

Employee history

Education / Training history

License / Registration / Certificate

Work History

Job number 2

Job number 3