Position(s) applied for: (required) Date of Application: (use mm/dd/19xx format) (required) How did you learn about us? (required) Social Security Number If you are under 18 years of age, can you provide required proof of your eligibility to work? (required) Have you ever filed an application with us before? (required) If yes, give date: Have you ever been employed with us before? (required) If yes, give date: Are you currently employed? (required) May we contact your present employer? (required) Are you legally permitted to work in the United States? (proof required upon employment) (required) On what date will you be available for work? (required) Are you available to work: (required) Are you currently on "lay-off" status and subject to recall? (required) Can you travel if a job requires it? (required) Have you been convicted of a felony within the last 7 years? (required) If yes, please explain: (conviction will not necessarily disqualify applicant from employment.) Employment Experience - Start with your present or last job.
1) (Most recent employer:) 2) 3) 4) List any professional, trade, business or civic activities and offices held. Other Qualifications: (Summarize any related skills and qualifications) Specialized Skills: State any additional information you feel may be helpful to us in considering your application: Education
High School: (required) Undergraduate College: Graduate/Professional Other: (specify) References: An Equal Opportunity Employer
General Agreement: By filling out and submitting this application online I understand that all offers of employment are conditioned on receipt of satisfactory responses to reference requests and the provision of satisfactory proof of an applicant's identity and legal authority to work in the United States. In consideration of my employment, I agree to conform to the rules and standards of the practice, as amended from time to time at the employer's discretion. Authorization to Check References: By filling out and submitting this application online, I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any information checked unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals whom the practice may contact, to provide any and all information concerning my previous employment and any other pertinent information they may have. Further, I release all parties and persons from all liability for any damages that may result for furnishing the practice with such information as well as from the use or disclosure of such information by the employer or any of its agents, employees or representatives. I understand that any misrepresentation, falsification, or omission of material information on this application may result in my failure to receive an offer, or, if I am hired, in my dismissal from employment. Employment Relationship: By filling out and submitting this application online, I acknowledge that, if employed, I understand that employment with the practice is not for a specified term and can be terminated "At Will", with or without cause, and with or without notice, at any time, either at the option of the employee or the employer. This "At-Will" employment policy includes all employees including those presently employed by the practice. No employee or representative of the practice, other than its owner, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Further the employer may not alter the "At-Will" nature of the employment relationship unless it is done specifically and in writing that is signed by the employer. I agree that this constitutes a final and fully binding agreement with respect to the "At-Will" nature of my employment relationship. There are no oral or collateral agreements regarding this issue.
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