Employment Application


Have You ever been employed by any of our clinics?
Due to nature of our business and the importance of meeting the need of our patients, you may be required to work on different shifts or possible different locations. Would this be an issue?
Have you ever been convicted of a felony?
All applicants are required to proof of diploma, degree, transcripts, licenses, certifications

Do you graduate/achieve GED?
Type of school Name & location of School Dates Attended Graduated Type of Diploma Degree Major/Minor Field of study
FROM TO YES NO
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License/Certificate Date Issue Expiration Date Issued By(state or other authorities) License Number Location of issuing Authority(city & state)
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Do you have computer skills? Yes No
Do you speak English? Yes No
Do you speak a language other than english?Yes No
How Fluently? Fair Good Excellent

Start with your present or last job. 

Include any job related military service assignments and volunteer activities.
Employer Name Dates Employed Worked Performed
FROM TO
Hourly Rate/Salary
 
Address
Telephone Number
Starting/Present Job Title
Supervisior Name
Reason For Leaving
    May We Contact? Yes No
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List three character references

This should be someone other than a relative who can provide information on your employment potential.

Reference 1

Reference 2

Reference 3