* Name:
* Email Address:
* Address:
SSN:
* City:
* State:
* Zipcode:
* Telephone Number:
* Are you over 18 years old?
Yes
No
* Are you authorized to work in the US on an unrestricted basis?
Yes
No
How did you learn of this opening? (Referred By)
Are there any hours, shifts or days you cannot or will not work?(please list)
* Employment Preferred:
Part Time
Full Time
* Are you willing to work overtime as required?
Yes
No
* Have you ever been convicted of a felony?
Yes
No
(Conviction will not necessarily disqualify an applicant for employment)
If yes, describe conditions:
Special Skills:
Positions applied for:
* 1.
2.
Wage or salary desired?
When can you start?
WORK HISTORY
Most Recent Employer:
Address:
Phone:
Date Started:
Starting Salary:
Per
Starting Position:
Date Left:
Salary on Leaving:
Per
Position on Leaving:
Name and Title of Supervisor:
Reason for Leaving:
Description of Duties:
Employer Before Above:
Address:
Phone:
Date Started:
Starting Salary:
Per
Starting Position:
Date Left:
Salary on Leaving:
Per
Position on Leaving:
Name and Title of Supervisor:
Reason for Leaving:
Description of Duties:
Employer Before Above:
Address:
Phone:
Date Started:
Starting Salary:
Per
Starting Position:
Date Left:
Salary on Leaving:
Per
Position on Leaving:
Name and Title of Supervisor:
Reason for Leaving:
Description of Duties:
APPLICANT'S CERTIFICATION AND AGREEMENT
I certify that the facts set forth in this Application for Employment are true and complete to the best of my
knowledge. I understand that if I am employed, false statements may result in my dismissal. I authorize the Highland
Clinic to make an investigation of any of the facts set forth in this application.
I understand that the employment at Highland Clinic is "at will," which means that either I or the Highland Clinic can
terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by
statute. All employment is continued on that basis. I understand that no supervisor, manager or executive of
Highland Clinic, other than the resident has any authority to alter the foregoing.
I understand that it is the Highland Clinic's policy to require that all candidates who are selected for employment
undergo a substance abuse screening test prior to employment. In case of a positive test, I understand that the offer
for employment will be withdrawn.
I agree to comply with the clinic rules, regulations and policies, and acknowledge that these
rules, regulations and policies may be changed, interpreted, withdrawn, or supplemented any time,
and without prior notice to me.
I acknowledge that any offer of employment, or my acceptance of an employment offer, if such is
to occur, may be withdrawn, with or without cause, and with or without prior notice, at any time,
at the option of the clinic or myself. I understand that this application and any other
documents which I may receive are not contracts of employment. I further understand that no
representative of the clinic other than an officer has any authority to enter into any agreement
for employment for any specified period of time or to assure any other personnel action, either
prior to commencement of employment or after I have become employed, or to assure any benefits or
terms and conditions of employment, or make any agreement contrary to the foregoing.
* May we contact your present employer? Yes
No
