I Agree to comply with the above statements:
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Social Security Number: (required)
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Date: (required)
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E-Mail Address: (required) :
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Position(s) applied for: (required)
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Rate of pay expected $:
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Per: :
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Would you work:
Full-time
Part-time
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Specify days and hours if Part-Time:
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List any friends or relatives working here
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If your application is considered favorably, on what date will you be available to work?: (required)
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Other work experiences, skills, or qualifications that you feel would fit you for work here?:
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Are you a U.S. Citizen?: (required)
Yes
No
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If no, do you have a valid work permit?:
Yes
No
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Have you ever been convicted of a felony?: (required)
Yes
No
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If yes, please explain:
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Have you previously applied here?:
Yes
No
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If yes, when?:
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Have you worked for any firm under a different name?:
Yes
No
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Any physical conditions which would limit your performance of the job you are applying for?: (required)
Yes
No
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If yes, please explain:
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PERSONAL REFERENCES (Not former employers or relatives) |
Reference 1: Name and Occupation:
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Reference 1: Address:
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Reference 1: Phone Number:
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Reference 2: Name and Occupation:
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Reference 2: Address:
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Reference 2: Phone Number:
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Reference 3: Name and Occupation:
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Reference 3: Address:
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Reference 3: Phone Number:
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MEMBERSHIP IN SCHOOL, PROFESSIONAL, OR CIVIC ORGANIZATIONS
(Do not include racial, religious, or nationality groups) |
Name or Description of Organization #1:
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Participated From:
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Participated To:
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Offices Held:
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Name or Description of Organization #2:
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Participated From:
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Participated To:
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Offices Held:
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Name or Description of Organization #3:
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Participated From:
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Participated To:
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Offices Held:
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Name or Description of Organization #4:
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Participated From:
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Participated To:
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Offices Held:
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EDUCATION RECORD |
Name of High School: (required)
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High School Start Date: (required)
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High School End Date: (required)
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Degree Awarded:
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High School Grade Point Average (GPA):
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Name of College/University:
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College/University Start Date:
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College/University End Date:
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Degree Awarded:
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College/University School Grade Point Average (GPA):
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Name of Business/Vocational School:
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Business/Vocational School Start Date:
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Business/Vocational School End Date:
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Degree Awarded:
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Business/Vocational School Grade Point Average (GPA):
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Do you type?:
Yes
No
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Words Per Minute (WPM):
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Office Machine and Computer Experience:
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WORK HISTORY
(Beginning with the most recent, list below all past employers, including any pertinent military experience) |
Job #1
Most recent job information |
Name of Company:
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Business Address:
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City:
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State:
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Phone Number:
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Type of Business:
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Immediate Supervisor:
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Date Employed From:
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Date Employed To:
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Exact Job Title:
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Earnings at Hire:
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At Termination:
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Reason for Termination:
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Description of Duties:
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Job #2 |
Name of Company:
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Business Address:
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City:
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State:
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Phone Number:
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Type of Business:
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Immediate Supervisor:
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Date Employed From:
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Date Employed To:
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Exact Job Title:
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Earnings at Hire:
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At Termination:
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Reason for Termination:
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Description of Duties:
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Job #3 |
Name of Company:
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Business Address:
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City:
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State:
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Phone Number:
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Type of Business:
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Immediate Supervisor:
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Date Employed From:
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Date Employed To:
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Exact Job Title:
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Earnings at Hire:
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At Termination:
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Reason for Termination:
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Description of Duties:
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AFFIDAVIT
I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I agree that the company shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in this questionnaire. I also authorize the companies, schools or persons named above to give any information regarding my employment, character and qualifications. I hereby release said companies, schools or persons from all liability for any damage for issuing this information. I certify that all statements and answers to questions about my health are true and were made by me without any reservations. I expressly waive all provisions of law prohibiting any physician, person, hospital or other institution that has or may hereafter attend or furnish me with treatment from disclosing to the company any knowledge or information thereby acquired. I understand that any misleading or incorrect statements may render this application void, and if employed, would be cause for termination. I understand that there is no express or implied contract of employment and that if employed I have been hired at the will of the employer and that my employment may be terminated at will, at any time; and with or without cause the employer's only obligation being to pay salary or wages due and owing at the time of the termination. Finally, I understand that all company property must be returned and my indebtedness to the company must be paid before my termination. I authorize the company to deduct from my final paycheck(s) all monies due and owing to the company. |
By submitting this form, you agree that all of the above stated information is true.
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After submitting your application
Please send your resume in an email to: ksmith@lindalevetclinic.com |
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