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Palms Medical Group
Application for Employment
mbarber@palmsmg.org

All information marked by "*" is required.
Application Date:Thursday, May 23, 2013
*Your First Name:
Your M.I.:
*Your Last Name:
*Social Security #:
*Your E-mail:
*Phone #:
Fax #:
*Your Address:
Street Address:
City:
State/Province:
Country:
Postal (zip) Code:
*Position Applying For:
*Date Available (MM/DD/YYYY)
Set start date
*Type of Employment:
*Location Applying For:
Referral Source and Name:
Where did you hear about this position?:
*If you are under 18, and it is required,
can you furnish a work permit?:
 		 YES    NO    I am over 18
If no, please explain:
 
*Have you ever been employeed
with this company before?:
 		 YES    NO
If yes, give dates and position(s):
 
*Are you legally eligible for
employment in this country?:
 		 YES    NO
*Can you meet the attendance requirements
of this position?:
 		 YES    NO
*Have you ever pled "guilty" or "no contest"
to, or been convicted of, a felony?:
(Answering "yes" to this question does not
constitute an automatic bar to employment.
Factors such as date of offense, seriousness
and nature of the violation, rehabilitation,
and position applied for will be considered.)
 		 YES    NO
Driver's License #:
(if driving is an essential job function)
 
*EMPLOYMENT HISTORY:
Name of Employer #1:
Address:
Phone#
Supervisor & Title
May we contact your supervisor? YES    NO
Job Title
Date Started (MM/DD/YYYY)
Set start date
Date Left (MM/DD/YYYY)
Set end date
Starting Pay
Ending Pay
Summary of work performed and Responsibilities:
Reason for Leaving:
Name of Employer #2:
Address:
Phone#
Supervisor & Title
May we contact your supervisor? YES    NO
Job Title
Date Started (MM/DD/YYYY)
Set start date
Date Left (MM/DD/YYYY)
Set end date
Starting Pay
Ending Pay
Summary of work performed and Responsibilities:
Reason for Leaving:
Name of Employer #3:
Address:
Phone#
Supervisor & Title
May we contact your supervisor? YES    NO
Job Title
Date Started (MM/DD/YYYY)
Set start date
Date Left (MM/DD/YYYY)
Set end date
Starting Pay
Ending Pay
Summary of work performed and Responsibilities:
Reason for Leaving:
Name of Employer #4:
Address:
Phone#
Supervisor & Title
May we contact your supervisor? YES    NO
Job Title
Date Started (MM/DD/YYYY)
Set start date
Date Left (MM/DD/YYYY)
Set end date
Starting Pay
Ending Pay
Summary of work performed and Responsibilities:
Reason for Leaving:
*EDUCATION:
High School
Name:
Address:
Graduate?: YES    NO
Major/Degree:
Course of Study:
College
Name:
Address:
Graduate?: YES    NO
Major/Degree:
Course of Study:
Other
Name:
Address:
Graduate?: YES    NO
Major/Degree:
Course of Study:
*REFERENCES:
Name #1
Phone #
Years Known
Name #1
Phone #
Years Known
Name #3
Phone #
Years Known
*APPLICATION STATEMENT

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respsect, will be sufficient cause to (1) cancel further consideration of this application; or (2) immediately discharge me from the employers service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuray of all information provided by me in this application, resume, or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations, and organizations for furnishing such information about me.

I also understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on the basis prohibited by applicable local, state or federal law. I understand that the employer does not unlawfully discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on the basis prohibited by applicable local, state or federal law.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same rights to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the forgoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 form in this regard.

DO NOT SUBMIT THIS APPLICATION UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

By submitting this form, you certify that you have read, fully understand, and accept all terms of the foregoing Applicant Statement.

    Clear

 
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This institution is an equal opportunity provider and employer.
This health center is a Health Center Program grantee under 42 U.S.C. 254b,
and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).

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