Pinehurst Medical Clinic Employment Application

AN EQUAL OPPORTUNITY EMPLOYER

Application of Employment
Please Read Before Filling Out This Application.
Incomplete or Unsigned Applications Will Not Be Accepted.

Pinehurst Medical Clinic, Inc. does not discriminate in hiring or employment on the basis of race, color, sex, religion, disability, national origin, citizenship, or on the basis of age with respect to persons 18 years or older. No question on this application is intended to secure information to be used for such discrimination. Proof of identity and work authorization will be required upon employment in accordance with federal regulations. This Clinic intends to check and hold you responsible for the accuracy of the statements you make on this application. This application will receive consideration for sixty (60) days. If you have not heard from the Company within sixty days and wish to receive further consideration for employment, it will be necessary to complete another application form.

Personal Data

Mailing Address:
Street: City: State: Zip:

Physical Address: Physical Address is the same as the Mailing Address

Street: City: State: Zip:

Telephone: Are you 18 years of age or older? Yes No

General Information

Job Applied for: Desired Salary Range: $

How did you learn of us? Advertisement:     Employment Agency:
                                       Friend/Relative:     Job Line:
                                       Other: (Please Specify )
Date Available for work: ( mm/dd/yy )
Have you applied here before?                     Yes No    If Yes, when?
Have you ever worked for PMC before?      Yes No    If Yes, when?
If Yes, give the name(s) if different from the one given on this application:
Type of Employment Sought: Temporary Position Permanent Position
Number of Hours Per Week: Full Time   Part Time
Can you travel if a job requires it? Yes No
Have you ever been convicted of a crime other than a minor traffic violation? Yes    No
If YES, explain:
                ( A "yes" answer to this question does not necessarily preclude consideration for employment )

Military Service

Are you a veteran? No Yes If YES, indicate Date of Military Service:
Are you a member of the Military Reserve? No Yes

Educational Data

What is the highest grade completed?
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 1 2 3 4
Grade, Junior High, or High School College or University Graduate School

Type of School	Name of School	Location	Graduate?	Major Subject or Course of Study	Degree(s) Obtained
High School
College(s) University(s)
Other Educational vocational school, internship, etc.
Graduate or Professional

Special Skills, Certifications, Licensures

Please check all that apply:

Please list any additional knowledge, skills, and abilities you wish considered. Include equipment or machines you operate, special computer languages, laboratory techniques, etc:

Professional License(s)/Certification(s) including numbers, expiration dates, and sources of issuance:
1)
2)
3)

Work History ( List employment history from most current position to earliest. )

From (mo./yr.): To (mo./yr.):
Starting Salary: $ per Final Salary: $ per
Company: Telephone: If this is your current employer, may we contact YesNo
Street: City: State: Zip:
Supervisor's Name: Type of Business:
Your Position/Title: Responsibilities/Duties:
Specify Reason for Leaving:

Briefly explain any gaps in employment:

References

Give three professional references who are not relatives or past supervisors:

Name:	Occupation:	Years Known:	Telephone:	Best time to call:

Affidavit

I hereby affirm that the information provided on this application, and accompanying resume (if applicable) is true and complete to the best of my knowledge. In the event of employment, I understand that false, misleading, or omitted information given in my application or interview (s) may result in discharge. I understand, also that I am required to abide by all rules and regulations of the employer. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

I authorize persons, schools, my current employer (if applicable), and previous employers and organizations named in this application and accompanying resume to provide any relevant information that may be required to arrive at an employment decision.

I understand that as a condition of employment, I must successfully pass a drug test.

I authorize Pinehurst Medical Clinic, Inc. to perform any applicable records checks, including but not limited to, a criminal records check and/or a driver's record check for the position I am being considered for.

Signature: Date:

by entering your name as a signature and by checking this box you wish to submit this Application and affirm that all information is correct.