After Hours Pediatrics Employment Form

Personal Information - Step 1
Our Commitment to Applicants

We appreciate your interest in starting, continuing or resuming a career at After Hours Pediatrics. If you take the time to complete our employment process, we promise you and all applicants the following things in return:

- All qualified applicants will be considered for employment regardless of race, color, religion, age, genetic information, gender, pregnancy, national origin, sexual orientation, disbility or martial status.

- We will provide reasonable accommodations to individuals with diabilities.

- The personal information you provide After Hours Pediatrics will be used solely for Human Resource purposes, including compliance with federal and state employment laws. It will not be sold to other companies nor will it be shared with employees not involved in recruiting, screening, hiring, record-keeping or human resource management.

Your Commitment to After Hours Pediatrics

Integrity is a very important value at After Hours Pediatrics. Therefore, the information you provide our company during the application and screening process must be complete and accurate. Providing false information will result in your application being rejected or, if you are hired before the dishonesty is discovered, your immediate termination.

Please complete the entire application. You may attach a resume but you must still complete all questions or your application will be deemed incomplete and may not be considered. Please fill out each box and don't just indicate "See resume".

After Hours Pediatrics is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law.

Applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the organization.
Full Name*

First NameLast Name
Date:

MonthDayYear
Hour MinutesAM/PM Option
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Best Telephone Number to reach you: *
E-mail*
example@example.com

Employment History - Step 3
Provide all employment information for your past 3 employers starting with the most recent.
Employer Name*
Position*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Telephone #*
Employed From*

MonthDayYear
Employed To*

MonthDayYear
Supervisor's name and title*
Job Summary*
Reason for leaving*
Do you have more work experience?*

YesNo
Employer Name
Position
Employer Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Telephone #
Employed From

MonthDayYear
-
Employed To

MonthDayYear
Supervisor's name and title
Job Summary
Reason for leaving
Do you have more work experience?

YesNo
Employer Name
Position
-
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Telephone #
Employed To

MonthDayYear
Employed From

MonthDayYear
Supervisor's name and title
Job Summary
Reason for leaving
May we contact all of the employers listed above?

YesNo
If not, which ones should we not contact and why?

Other Skills and Qualification - Step 4
Summarize any job-related training, skills, licenses, certificates, and/or other qualifications. Include relevant computer systems and software packages of which you have a working knowledge, and note your level of proficiency (basic, intermediate, expert). Describe any training and work experience which relates to the position for which you are applying.*

Educational History - Step 5
List school name and location, years completed, course of study, and any degrees earned.
Do you hold a HS diploma or GED certificate?*

YesNo
College (s)
Name
Location
Degree earned
Major
Name
Location
Degree earned
Major
Name
Location
Degree earned
Major
Technical Schools
Additional Technical Training
What interest do you have outside of work that complement your job skill?*

References & Authorization - Step 6
List 3 references' names, phone numbers, and years known (no relatives or employers)
1.
Full Name*

First NameLast Name
Phone Number*
Years Known*
How do you know this person?*
2.
Full Name*

First NameLast Name
Phone Number*
Years Known*
How do you know this person?*
3.
Full Name*

First NameLast Name
Phone Number*
Years Known*
How do you know this person?*
What other information would you like to share that would aid us in understanding your desire and qualifications for the position?*
Do you have a resume you would like to upload?*

YesNo
Upload your resume*

Cancelof
Electronic Signature*

First NameLast Name
Application Completed*

MonthDayYear
Hour MinutesAM/PM Option
Applicant acknowledge & authorization to release employment reference Information

PLEASE READ CAREFULLY

I certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with After Hours Pediatrics and for no other reason. I understand that After Hours Pediatrics requires certain information about me to evaluate my qualifications for employment and to conduct its business if I become an employee.

I agree and understand that After Hours Pediatrics and its agents may investigate or seek information concerning my background and/or previous employment, whether of record or not, to the extent and for purposes permitted by applicable federal ands state law. I further agree and understand that if employed, the Company may at any time seek any information from whatever source, which is its discretion, it deems relevant information about my employment, to the extent and for purpose permitted by applicable federal and state law. Accordingly, I hereby authorize the previous employers and references listed in my application or any other source contacted by the Company to give the Company any and all information requested by the Company concerning my previous employment or any other information they may have, personal or otherwise. I hereby release the company and its agents, the previous employers, and any other persons or entities whatsoever involved in such an investigation or inquiry from all liability of any kind, including any damages on account of the furnishing of such information. After Hours Pediatrics may be required to disclose applicant information without notice or consent under subpoenas, warrants, orders or by lawfully authorized requirement or demand under the authority of the laws of the United States.

After Hours Pediatrics does not hire persons who use illegal drugs. All persons seeking employment or employed at After Hours Pediatrics may be required to take and pass a screen for illegal drugs, and may be subject to periodic testes for illegal drugs. I hereby voluntarily consent to provide a urine specimen (or blood specimen) as required at a collection facility designated by After Hours Pediatrics, and further consent to have the specimen tested at a laboratory selected by After Hours Pediatrics. I hereby certify that I do not use illegal drugs. I understand that I may be required to submit to drug testing not or at any time in the future and I agree to such testing. I also understand that I may be required to submit to a medical evaluation or other screening relating to the industry.

I understand that if I am employed by After Hours Pediatrics, I must conform to the rules, regulations, ad directives of After Hours Pediatrics. I understand that I have the right to terminate my employment at any time with or without notice, with or without cause, and that After Hours Pediatrics does not constitute a guarantee that any position by continued for any length of time or that any job assignment or shift by permanent. I understand that I may be required to work scheduled and unscheduled overtime and scheduled weekend and holiday work when required by After Hours Pediatrics. I understand that no one other than the President of After Hours Pediatrics has the authority to make any other agreement.

I understand that if I am hired, confidential information regarding After Hours Pediatrics, and/or its customers and employees may be available to me and that this information must not be disseminated or used except for After Hours Pediatrics' benefit. If employed, I agree to keep all information about After Hours Pediatrics, including, such information regarding its business methods, customers and employees, confidential and shall not disclose this information to any unauthorized personnel.

I certify that all statements made by me on this application are true and complete to the best of my knowledge and I understand that false, incomplete or misleading statements or omissions on this application or any other pre- or post- employment for may be considered sufficient cause for dismissal, if and when discovered.

I hereby acknowledge that I have read, understand, and consent to the above statements.

The use of this application does not indicate there are positions open and does not in any way obligate After Hours Pediatrics. The application will be considered valid for no longer than 45 days.

An Equal Opportunity Employer
Signature*

Clear
Date:*

MonthDayYear
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