Prairie_Clinic_Application

APPLICATION FOR EMPLOYMENT
Last Name*
First Name*
Middle Name*
Street*
City*
State*
Zip*
Length of time at current address*
Social Security No*
Phone number where you can be reached*

Area CodePhone Number
Email Address*
If under 18 do you have a Work Permit?*

N/AYesNo
EMPLOYMENT DESIRED
Position (s) applied for:
1st Choice Position
Salary Desired
2nd Choice Position
Salary Desired
Do you have a preference for days or hours available?

YesNo
Days/Hours available to work
Mon
Tue
Wed
Thur
Fri
Sat
Sun
Employment desired:

FULL-TIME ONLYPART-TIME ONLYFULL OR PART-TIME
How many hours can you work weekly?
Can you work nights?

YesNo
When would you be available for work
I understand that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as directed by my department head or administrator of this institution. - HR*

I UNDERSTAND
If your availability status changes, it is your responsibility to notify your department head or the administrator. Such changes will be effective, then for any future employment.*

I UNDERSTAND
EDUCATION/TRAINING:
NAME & ADDRESS OF High School
# YEARS COMPLETED High School
Graduated High School

YesNo
Major & Degree High School
NAME & ADDRESS OF SCHOOL_College
# YEARS COMPLETED College
Graduated College

YesNo
Major & Degree College
NAME AND ADDRESS OF SCHOOL_Lab/X-Ray/Other Training
# YEARS COMPLETED Lab/X-Ray/Other Training
Graduated Lab/X-Ray/Other Training

YesNo
Major & Degree Lab/x-Ray/Other Training
PROFESSIONAL LICENSES AND/OR CERTIFICATIONS
Certification #1
TYPE - Certification #1
ORGANIZATION OR STATE ISSUED - Certfication #1
DATE ISSUED - Certification #1
NUMBER - Certification #1
VERIFICATION - Certification #1
Certification #2
TYPE - Certification #2
ORGANIZATION OR STATE ISSUED - Certification #2
DATE ISSUED - Certification #2
NUMBER - Certification #2
VERIFICATION - Certification #2
Certification #3
TYPE- Certification #3
ORGANIZATION OR STATE ISSUED - Certification #3
DATE ISSUED - Certification #3
NUMBER - Certification #3
VERIFICATION - Certification #3
Certification #4
Click to edit
TYPE- Certification #4
ORGANIZATION OR STATE ISSUED - Certification #4
DATE ISSUED - Certification #4
NUMBER - Certification #4
VERIFICATION - Certification #4
WORK EXPERIENCE:
Work Experience #1 - Name of employer
Address ( City State Zip Code)
Phone #
Employment Dates- FROM
Employment Dates- TO
Your last job title
Starting Pay
Final Pay
May we contact for reference?

YesNo
Name of last supervisor
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Work Experience #2 - Name of employer
Address ( City State Zip Code)
Phone #
Employment Dates- FROM
Employment Dates- TO
Your last job title
Starting Pay
Final Pay
May we contact for reference?

YesNo
Name of last supervisor
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Name of employer #3
Address ( City State Zip Code)
Phone #
Employment Dates- FROM
Employment Dates- TO
Your last job title
Starting Pay
Final Pay
May we contact for reference?

YesNo
Name of last supervisor
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Name of employer #4
Work Address ( City State Zip Code)
Phone #
Employment Dates- FROM
Employment Dates- TO
Your last job title
Starting Pay
Final Pay
May we contact for reference?

YesNo
Name of last supervisor
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
CRIMINAL BACKGROUND:
Have You Ever Been Convicted of a Crime?

YesNo
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were
BACKGROUND:
Please list your short-term professional goals:
Please list your long-term professional goals:
What was your favorite job, and why?
What was your least favorite job, and why?
REFERENCES:
Name & Relationship Reference #1
Title - Reference #1
Company Name & Address
Phone Number
Name & Relationship- Reference #2
Title - Reference #2
Company Name & Address
Phone # of Reference #2
Name & Relationship- Reference #3
Title of Reference #3
Company Name & Address
Phone of Reference #3
Additional Information and Summarization
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.
Did you complete this application yourself?

YesNo
If not, who did?
DateTime
APPLICATION FORM WAIVER
This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.
Should be Empty:

APPLICATION FOR EMPLOYMENT

EMPLOYMENT DESIRED

Position (s) applied for:

Days/Hours available to work

EDUCATION/TRAINING:

PROFESSIONAL LICENSES AND/OR CERTIFICATIONS

Certification #1

Certification #2

Certification #3

Certification #4

WORK EXPERIENCE:

CRIMINAL BACKGROUND:

BACKGROUND:

REFERENCES:

Additional Information and Summarization

APPLICATION FORM WAIVER