Please complete the following application.

Name and Location
Name: (First, Middle, & Last)
Current Address: (Street Number & Name)
Home Phone:
City, State, Zip Code
Phone Number for Message:
Employment Desired
First Position Desired:
Experience?
Second Position Desired:
Experience?
Have you worked for us before?
If yes, when?
Have you worked for us before under another name?
If yes, state name.
Will You Accept Part Time Work?
Will You Accept Temporary Work?
Shift or Hours You Can Work
Other
Citizenship
Are you either a United States citizen or an alien who has the legal right to work in the job for which you are applying?
Pursuant to the Immigration Reform and Control Act of 1986. All applicants, upon being made an offer of employment, must produce documents. Which are specified by the federal government. Establishing their identity and authorization for employment in the United States. These documents must be produced no later than (72) hours after commencement of employment. You will also be required to sign form I-9 (issued by the federal government) verifying under oath. Your employment authorization.
U.S. Military Service
Have you served in the U.S. Military?
Please list job-related skills or experience.
Statement of Health
Can you perform the essential functions of the position for which you are applying safely?
Explain:
Are you willing to take a physical examination and/or drug test at our expense upon a conditional offer of employment?
Personal
Have you, since the age of 18, ever been convicted of a felony?
If yes, please explain and give dates: (A conviction will not necessarily disqualify you.)
Have you ever been involuntarily discharged?
If yes, please explain and give dates:
Have you any hobbies or interests, or belong to any club, organization, society or professional group which has a direct bearing on your qualification for the job which you are seeking? You may omit those which indicate your race, religious creed, color, national origin, ancestry, sex, age, physical or mental impairment, or medical condition.
If yes, please explain:
Education & Training
Entry 1
Last High School: (Name & Location)
Major:
Years:
Diploma?
Entry 2
Jr College/College/University: (Name & Location)
Major:
Years:
Diploma?
Entry 3
Technical or Vocational School: (Name & Location)
Major:
Years:
Diploma?
Other details of experience or training, school course diploma or certificate? Date completed.
References

Give names of persons we may contact to verify your qualifications for the position.

Reference 1
Name:
Address:
Phone:
Occupation:
Organization:
Reference 2
Name:
Address:
Phone:
Occupation:
Organization:
Reference 3
Name:
Address:
Phone:
Occupation:
Organization:
Experience

Give a complete record of all employment and reasons for periods of unemployed during the past 15 years. Start with most recent employment.

Employment 1
Employer:
Phone:
Street Number and Name
City, State, Zip Code
Employment From:
/
Employment To:
/
Salary:
Position:
Supervisor: (Name & Title)
Reason for Leaving:
Employment 2
Employer:
Phone:
Street Number and Name
City, State, Zip Code
Employment From:
/
Employment To:
/
Salary:
Position:
Supervisor: (Name & Title)
Reason for Leaving:
Employment 3
Employer:
Phone:
Street Number and Name
City, State, Zip Code
Employment From:
/
Employment To:
/
Salary:
Position:
Supervisor: (Name & Title)
Reason for Leaving:
Employment 4
Employer:
Phone:
Street Number and Name
City, State, Zip Code
Employment From:
/
Employment To:
/
Salary:
Position:
Supervisor: (Name & Title)
Reason for Leaving:
Employment 5
Employer:
Phone:
Street Number and Name
City, State, Zip Code
Employment From:
/
Employment To:
/
Salary:
Position:
Supervisor: (Name & Title)
Reason for Leaving:
May we contact your present employer for a reference?
Typing Speed:
List office machines you can use:
Please list what other equipment you can operate (if applicable):
Equipment 1:
Repair:
Setup:
Equipment 2:
Repair:
Setup:
Equipment 3:
Repair:
Setup:
Can you transcribe Dr's orders?
Professional Licenses, Registrations, and/or Certifications
License/Registration/Certification 1
Type:
State:
Date:
Number:
License/Registration/Certification 2
Type:
State:
Date:
Number:
License/Registration/Certification 3
Type:
State:
Date:
Number:
Areas of specialization or major interest:
Affidavit

I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever, I agree that my employer shall not be liable in any respect if my employment is terminated because of the falsity of statements, answers or omissions made by me in the questionnaire. I authorize employers, companies, schools or persons named above to give any information regarding my employment, together with any information they may have regarding me whether or not it is in their records. I hereby release said employees, companies, schools or persons from all liability for any damage both legal and otherwise, for issuing this information. I also understand a conditional offer of employment may be based on results of a later medical examination. In addition, if accepted for employment, I hereby agree to abide by the rules and policies of my employer.

Further, I understand that any employment is not for a stated period of time and may be terminated with or without cause, at any time, at the option of either myself or my employer. In addition, should my employer be or become subject to the conditions of the Drug-Free Workplace Act of 1988, I agree to abide by such established policies as relates thereto.

Applicant Signature:
Date of Application:

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