Elberta Clinic Employment Application

Elberta Family Medical Clinic

EMPLOYMENT APPLICATION
Failure to complete all sections of this application may disqualify an applicant from consideration. This application will remain on file for one year and active for one month. Applicants are considered on the basis of qualifications without regard to race, color, religion, sex, national origin, age, marital status, veteran status, disability, genetic status, or sexual orientation.
Referred By:
PERSONAL INFORMATION
Date
Name:

First NameMiddle InitialLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Contact Number
Phone numberFormat: (000) 000-0000.
Are you 18 years old or older?
Email Address
example@example.com
Are you legally authorized to work in the U.S.?
Are you able to perform the job's essential functions for which you are applying, with or without reasonable accommodation?
EMPLOYMENT DESIRED
Position:
Date you can start
Salary desired:
Check any or all that apply:
Are you currently employed?
May we inquire of your present employer?
EDUCATION, EXPERIENCE, AND SKILLS:
Highest grade completed in High School:
Diploma:
GED:
Name of High School
City/State
Number of years attended at Trade School:
Junior College:
College:
Other
College(s) and City/States
Degree Received:
List professional, trade, business, or civil activities and any offices held (you may exclude organizations that would indicate the race, sex, age, marital status, color, national origin, or the ability of its members)
Other Professional Skills:
Have you ever been terminated or asked to resign by an employer? If yes, explain.
If yes, explain.
N/A if the answer is No
Have you ever been convicted of a felony?
(a conviction record will not necessarily be a bar to employment). If yes, what was the nature of the offense, when, where, and the outcome?
FORMER EMPLOYERS - List below the last three employers, starting with the most recent. Incomplete information could disqualify you from further consideration.
Start/End Date:
Employer Name:
Phone:
Phone NumberFormat: (000) 000-0000.
Job Title:
Job Title
City/State:
City/State
Duties:
Brief summary of job duties
Reason for leaving:
Start/End Date:
Employer Name:
Phone:
Phone numberFormat: (000) 000-0000.
Job Title:
City/State:
Duties:
Reason for leaving:
Start/End Date:
Employer Name:
Phone:
Phone numberFormat: (000) 000-0000.
Job Title:
City/State:
Duties:
Reason for leaving:
REFERENCES

For employment consideration, references must be listed.

References Required

Rows	Name	Company Name	Contact Number	How Long?
1
2
3

Please read carefully before signing.
Elberta Clinic is an equal-opportunity employer. Elberta Clinic does not discriminate in employment based on race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual orientation, marital status, physical or mental disability, military status, or unfavorable discharge from military service.
I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Elberta Clinic to hire me. If I am hired, I understand that either Elberta Clinic or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of Elberta Clinic has the authority to make any assurance to the contrary.
I attest by my signature below that I have provided Elberta Clinic with accurate and complete information on this application. No requested information has been concealed. I authorize Elberta Clinic to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.
By typing my full name below, I acknowledge that this serves as my electronic signature and that the information provided is accurate and complete.
Signature Date
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Elberta Family Medical Clinic

PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION, EXPERIENCE, AND SKILLS:

FORMER EMPLOYERS - List below the last three employers, starting with the most recent. Incomplete information could disqualify you from further consideration.

REFERENCES