WEST TEXAS HEALTH
All applicants will be considered for employment without regards to race, religion, color, sex, national origin, age, marital or veteran status, disability, sexual orientation, gender identity, gender expression, or any other status protected by law. We are an Equal Opportunity Employer.
PERSONAL INFORMATION
Date
-
Month
-
Day
Year
Date
Name
First Name
Middle Initial
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone No.
Format: (000) 000-0000.
Email:
example@example.com
Referred by
Are you 18 years of age or older?
Yes
No
EMPLOYMENT DESIRED
Position
Full-time Part-time
Full-time
Part-time
Date you can start
-
Month
-
Day
Year
Date
Salary desired
Are you employed now?
Yes
No
If yes, may we contact your present employer?
Yes
No
Have you ever been employed by Abilene Diagnostic Clinic or West Texas Health?
Yes
No
Do you have any relatives working for West Texas Health?
Yes
No
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EDUCATION
EDUCATION
Rows
Name and location
Select last year completed
Did you graduate?
Subjects studied and degree(s) received.
High School
College
Trade or Business School
GENERAL
Indicate special qualifications or skills.
Have you ever been convicted of a crime, excluding minor traffic offenses?
Yes
No
If yes, please explain:
Conviction will NOT necessarily be a bar to employment. Each instance and explanation will be considered in relation to the position for which you are applying.
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PRIOR EMPLOYMENT (Start with most recent employer. MUST COMPLETE.)
Most recent employer:
Phone:
Format: (000) 000-0000.
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Address:
Position:
Supervisor:
Duties:
Starting Salary:
Final Salary:
Reason for leaving
Employer 2:
Phone:
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Address:
Position:
Supervisor:
Duties:
Starting Salary:
Final Salary:
Reason for leaving
Employer 3:
Phone:
Format: (000) 000-0000.
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Address:
Position:
Supervisor:
Duties:
Starting Salary:
Final Salary:
Reason for leaving
Please account for periods of unemployment:
Attach your resume here
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MILITARY SERVICE
MILITARY SERVICE
Rows
Branch of service
From
To
Rank & duties
Date discharged
1
PERSONAL REFERENCES (First and last name. MUST COMPLETE.)
PERSONAL REFERENCES (First and last name. MUST COMPLETE.)
Rows
Name
Address
Years known
Telephone
1
2
3
I hereby authorize West Texas Health PLLC (WTH) to investigate all facts contained in my application for employment and authorize the release of any information by
my present and past employers and other references, which may be required for a reference check. I authorize my present and past employers and other references
to give any information concerning my employment and any other pertinent information which they may have, personal or otherwise, and release those parties and
WTH from any liabilities or damages which may result from the furnishing of said information.
I certify that the facts listed in my application for employment are true and correct to the best of my knowledge, and I understand that any false information,
misrepresentation or omission of facts shall be cause for rejection of this application or termination of employment. If employed, I understand that my employment
will be on an at will basis, not for any definite period, and may be terminated by either party at any time for any reason..
Date:
-
Month
-
Day
Year
Date
Signature of applicant
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