Application for Employment

North Platte Surgery Center Employment Application

Please complete all sections below. Applications are maintained for up to six months. If you wish to be considered after six months you must reapply. All applications are subject to review of various governmental agencies having regulatory authority over this company. An Equal Opportunity Employer
Name - First, Middle, Last
Application Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Social Security Number
Present Address - Street, City, State

Street Address

Street Address 2
CityState / ProvincePostal / Zip Code
Present Phone
Please enter a valid phone number.Format: (000) 000-0000.
Permanent Address - Street, City, State

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How were you referred to the Surgery Center? If referred by an employee, give name and relationship. List friends/relatives who work or previously worked for the Surgery Center.
Have you ever been employed by the Center?
If yes, give date(s) of employment.
Type of Employment Desired
Position Desired - 1st Choice
Position Desired - 2nd Choice
High School - Name and Address
High School - Did you graduate?
High School - Diploma/Degree
College - Name and Address
College - Did you graduate?
College - Diploma/Degree
Graduate School - Name and Address
Graduate School - Did you graduate?
Graduate School - Diploma/Degree
Technical/Business/Other School - Name and Address
Technical/Business/Other School - Did you graduate?
Technical/Business/Other School - Diploma/Degree
Now Attending - Undergraduate School
Now Attending - Graduate School
Now Attending - % Completed
Now Attending - Scholarships, Honors, etc.
List publications, theses, etc. Professional Credentials - Organizations, licenses, certifications, certificates
Foreign Language Proficiency - Language Name - Speaking, Reading, Writing
Software and Hardware Proficiencies
Significant Activities - High school and college activities and offices held. - Community and/or professional organizations and offices held
Work History

THIS SECTION MUST BE COMPLETED: List both paid and volunteer experience as applicable, starting with the LAST place worked FIRST. Account for the last 10 years or years worked if less than 10 YEARS. A resume can be substituted in place of completing the section on description of duties.
File Upload

Cancelof
Work History 1 - From (mo./yr.)

MonthDayYear
Date
Work History 1 - To (mo./yr.)

MonthDayYear
Date
Work History 1 - Company or Organization, Location, Phone Number, Supervisors Name
Work History 1 - Job Title/Position
Work History 1 - Describe Duties
Work History 1 - Reason for Leaving
Work History 1 - Salary Starting & Salary Last
Work History 2 - From (mo./yr.)

MonthDayYear
Date
Work History 2 - To (mo./yr.)

MonthDayYear
Date
Work History 2 - Company or Organization, Location, Phone Number, Supervisors Name
Work History 2 - Job Title/Position
Work History 2 - Describe Duties
Work History 2 - Reason for Leaving
Work History 2 - Salary Starting & Salary Last
Work History 3 - From (mo./yr.)

MonthDayYear
Date
Work History 3 - To (mo./yr.)

MonthDayYear
Date
Work History 3 - Company or Organization, Location, Phone Number, Supervisors Name
Work History 3 - Job Title/Position
Work History 3 - Describe Duties
Work History 3 - Reason for Leaving
Work History 3 - Salary Starting & Salary Last
Work History 4 - From (mo./yr.)

MonthDayYear
Date
Work History 4 - To (mo./yr.)

MonthDayYear
Date
Work History 4 - Company or Organization, Location, Phone Number, Supervisors Name
Work History 4 - Job Title/Position
Work History 4 - Describe Duties
Work History 4 - Reason for Leaving
Work History 4 - Salary Starting & Salary Last
Work History 5 - From (mo./yr.)

MonthDayYear
Date
Work History 5 - To (mo./yr.)

MonthDayYear
Date
Work History 5 - Company or Organization, Location, Phone Number, Supervisors Name
Work History 5 - Job Title/Position
Work History 5 - Describe Duties
Work History 5 - Reason for Leaving
Work History 5 - Salary Starting & Salary Last
Branch of U.S. Service - Military Schools Attended - Military Job Experience
Reference 1 - Name, Address, Occupation, Phone Number, Years Known
Reference 2 - Name, Address, Occupation, Phone Number, Years Known
Reference 3 - Name, Address, Occupation, Phone Number, Years Known
Are you willing to take a physical exam if a job offer is made?
Are you a smoker or tobacco user?
Physical

It is understood that employment at the Surgery Center is contingent upon my completing satisfactorily the required physical examination, including a drug test.
Are you legally eligible to work in the United States?
If you are under 18 years of age, can you provide proof of eligibility to work?
Have you ever been convicted of a felony?
If yes, date of last conviction

MonthDayYear
Date
Hour MinutesAM/PM Option
Convictions

Please list any convictions you have had for the following crimes in the space indicated below: Any felony or misdemeanor under Federal law or felony under State law for conduct relating to the development or approval of any drug product or relating to the regulation of any drug product under the Federal Food, Drug & Cosmetic Act, or a conspiracy to commit or aiding and abetting such criminal offense; Any felony which involves bribery, payment of illegal gratuities, fraud, perjury, false statements, racketeering, blackmail, extortion, falsification of destruction of records, interference with, obstruction of an investigation into, or prosecution of any criminal offence, or conspiracy to commit, or aiding or abetting, such felony.
For each conviction, include: Title and section of the Federal or State statute involved - Conviction and sentencing dates - Court entering judgment - Case or docket number - Brief description of the offense
Have you signed a secrecy and invention agreement in favor of any previous employer? If yes, name(s) of previous employer(s) with secrecy agreement
Are you under any obligation to a previous employer restricting your acceptance of employment with a competitive firm?
Agreement

Should I become an employee of the Surgery Center, I agree, in consideration of such employment, that I will not divulge to others or use for my own benefit any confidential information obtained during the course of my employment relating to sales, research and development, formulas, processes, methods, machines, manufactures, compositions, ideas, improvements, or inventions belonging to or relating to the affairs of the Surgery Center by whom I am employed. I certify that the answers provided by me hearing, and the representations made on my resume, if any, are to the best of my knowledge and belief, true and correct without reservation, and if found to be false would be considered by me as just cause for discharge. I further affirm that I have not knowingly withheld any facts or circumstances that would detrimentally affect this application. It is understood that employment at the Surgery Center is contingent upon my completing satisfactorily any required physical examinations, including a drug test. I further understand and agree that any offer of employment will be on an employment-at-will basis. As such, both the Center and I will have the right to terminate this employment at any time and for any reason. I hereby authorize this company to verify any and all information contained in this application and to inquire about my ability and qualifications for employment from former employers and others, and I hereby release all concerned from any liability in connection with gathering such information.
Applicant’s Signature
Signature Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

North Platte Surgery Center Employment Application

Work History

Physical

Convictions

Agreement