Fillable APPLICATION FOR EMPLOYMENT (Waco Family Medicine)

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APPLICATION FOR EMPLOYMENT (Waco Family Medicine)

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APPLICATION FOR EMPLOYMENT
AN EQUAL OPPORTUNITY EMPLOYER
Waco Family Medicine does not discriminate in hiring or employment on the basis of race, color, age, sex, religion,
creed,
national origin, ancestry, veterans or disability. No question on this application is intended to secure information to
be used for such discrimination. Waco Family Medicine will reasonably accommodate all applicants and employees with
disabilities if informed of such disability.
PLEASE PRINT DATE: ___________________
Name: _______ ___________________________________________________________________________________
L
ast First Middle
Addr
ess: ___________________________________________________________________________________________
Number Street City State Zip
Telephone (______)__________________________________ Social Security______/______/______
Perso
nal E-Mail _____________________________________
Are you eighteen years of age or older?
•
Yes
•
No
Have you filed an application here before?
•
Yes
•
No If yes, give date _____________________________
Have you ever been employed here before?
•
Yes
•
No If yes, give date _____________________________
and r
eason for leaving __________________________________________________________________________
Are you employed now?
•
Yes
•
No May we contact your present employer?
•
Yes
•
No
Any
friends or relatives working for this company? ___________________________________________________
What j
ob are you applying for? ___________________________________________________________________
Have you been convicted of a felony?
•
Yes
•
No
If Yes, please explain ________________________________________________________________________________
__
________________________________________________________________________________________________
(Such a conviction is not an automatic bar to employment. Any information supplied regarding the circumstances,
rehabilitation and age at the time will be considered. You may attach additional information which you want considered.)
Waco Family Medicine is a tobacco-free workplace and does not hire tobacco/e-cigarette users. Have you used tobacco/
e-cigarette products in the last 6 months?
•
Yes
•
No
On what date would you be available for work? ___________________________________________________________
Are y
ou available to work ______ full-time ______ part-time ______ other
Will you work overtime, if asked?
•
Yes
•
No Saturdays?
•
Yes
•
No
List an
y special considerations which would affect the hours you could work: __________________________________
________________________________________________________________________________________________
C
urrent and Former Employers:
(List below last three employers starting with the current or last one first.)
1. ____________________________________________________
____________________________________________
Business Address Telephone No.
__________________________________________________________________________________________________
Su
pervisor Your Position Dates Employed From To
___________
_______________________________________________________________________________________
Duties
__________________________________________________________________________________________________
Reason for leaving
2. __________________________
______________________________________________________________________
Business Address Telephone No.
__________________________________________________________________________________________________
Su
pervisor Your Position Dates Employed From To
__________________________________________________________________________________________________
Duties
__________________________________________________________________________________________________
R
eason for leaving
3. ________________________________________________________________________________________________
B
usiness Address Telephone No.
__________________________________________________________________________________________________
Su
pervisor Your Position Dates Employed From To
__________________________________________________________________________________________________
Du
ties
__________________________________________________________________________________________________
Reason for leaving
R
eferences:
Give below the names of three persons not related to you.
__________________________________________________________________________________________________
Name Address Telephone Years Known
__________________________________________________________________________________________________
1. ________________________________________________________________________________________________
2
. ________________________________________________________________________________________________
3. ________________________________________________________________________________________________
Sp
ecial skills and qualifications:
(Summarize any special skills and qualifications acquired.) ___________________
___
_______________________________________________________________________________________________
__________________________________________________________________________________________________
EDU
CATION
__________________________________________________________________________________________________
School Level Name & Number of Did you
Location
Years Attended
Gra
duate?
__________________________________________________________________________________________________
Gramm
ar
School ____________________________________________________________________________________________
High School _______________________________________________________________________________________
GED
_____________________________________________________________________________________________
College ___________________________________________________________________________________________
Trad
e or Business
School ____________________________________________________________________________________________
Other _____________________________________________________________________________________________
Hono
rs received: ___________________________________________________________________________________
ADDITIONAL INFORMATION
Use the s
pace below if you wish to volunteer additional information you feel may be helpful to us in considering your
application.
NOTE: PLEASE CAREFULLY READ THE STATEMENTS BELOW. AFTER YOU HAVE
READ THE STATEMENTS, PLEASE SIGN AND DATE IN THE SPACE PROVIDED
BELOW.
“I certify that the facts contained in this application and in any resume or other material provided to
Waco Family Medicine and in any oral statements by me are true and complete to the best of my
knowledge. I understand that, if employed, omissions, incomplete statements, or false statements on
this application or other materials supplied to Waco Family Medicine or in oral statements by me in the
hiring process shall be grounds for dismissal.
I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN. THIS
INVESTIGATION MAY CHECK CRIMINAL, CREDIT AND MOTOR VEHICLE RECORDS.
I agree to fully cooperate in this investigation, including personally requesting any information as
necessary. Further, I authorize the employers and references listed above to give Waco Family
Medicine any and all information concerning my previous employment and any pertinent information
they may have, personal or otherwise, and release all parties from all liability for any damage that may
result from furnishing same to Waco Family Medicine.”
I U
NDERSTAND AND AGREE THAT, IF HIRED:
1. My employment is for no definite period but may be terminated by Waco Family Medicine at any time
without any prior notice and without cause.
2. No officer or employee of Waco Family Medicine can guarantee me any specific salary or benefit or
employment for any period of time, except by written agreement between me and Waco Family Medicine
signed by the Secretary/Treasurer of Waco Family Medicine.
3. I will comply with all rules and regulations of Waco Family Medicine including the Drug-free Workplace,
Confidentiality and Tobacco-Free Workforce Policies. Failure to comply will result in employment and or
financial penalties as deemed by Waco Family Medicine. I understand that Waco Family Medicine’s rules,
regulations and policies are not a contract and may be changed or waived by Waco Family Medicine
at any
time.
Dat
e: __________________________ Signed: ____________________________________
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APPLICATION FOR EMPLOYMENT (Waco Family Medicine)

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Completed 15 March 2021

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