Employment Application

Employment Application

"An Equal Opportunity Employer" "A Non-Smoking Facility"
Representative know at this time. PLEASE COMPLETE ALL SECTIONS/BLOCKS BELOW.

Note: If you require assistance in completing this application, please let the Human Resource
DATE OF APPLICATION*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Telephone
Contact Telephone*
Email*
example@example.com
EMPLOYMENT/WORK DESIRED WITH COASTAL SKIN SURGERY AND DERMATOLOGY:
Position Desired*
Salary/Wage desired*
Date available for work*

MonthDayYear
Date
Position Time Frame*

Full TimePart TimeTemporary
Are there days you will not be able to work?*

YesNo
If "Yes" please specify.
Are you willing to work overtime as requested?*

YesNo
Are you willing to travel between our office locations?*

YesNo
Would you consider another position with our Practice?*

YesNo
Are you at least 18 years old?*

YesNo
Please list any other name(s) by which you may have been known (to verify education and work records):
Have you ever been employed by this organization?*

YesNo
If yes, what position?
Previous Position Start Date
Previous Position End Date
Do you have any relatives working for our Organization?*

YesNo
If Yes, provide the Name & Relationship
How were you referred to this organization?*
Are you a U.S. Citizen?*

YesNo
If "No" can you:

Produce identification such as a US Passport, driver's license, or photographic identification issue by the state?Submit a birth certificate, social security card, certificate of US citizenship or verification of your legal right to work?Provide proof of identity and employment eligibility will be required within three (3) days of hire.
Have you ever been convicted of a crime other than a minor traffic violation?*

YesNo
If "Yes" please explain.
Have you ever been dismissed or forced to resign from any employment?*

YesNo
If yes, please explain:
Military Service?*

YesNo
If yes, what Branch of Service?
Service Start Date
Service End Date
Highest Rank Obtained
Indicate any special job-related training obtained during your military service.
Educational RecordPlease list school name, city and state, majore field of study and degree earned, if any:
High School*
College or University*
Graduate School*
Technical/Business/Other School*
Are there other skills, training and/or courses of study that you have had relating to the position or type of work that you are seeking?
EMPLOYMENT RECORD: Chronologically list employment and unemployment for the past ten (10) years, beginning with your most recent employment. Additional employment record information is available on the following page. A resume may also be provided, but does not replace the information sought in this employment application. PLEASE NOTE THE NAME OF ANY EMPLOYER/SUPERVISOR WHOM YOU DO NOT WANT CONTACTED AT THIS TIME.
Do you have previous Employer information to add?*

YesNo
Employer
Address
City/State/Zip
Starting Position
Starting Salary
Last Position
Last Salary
Dates Empoyed
Duties
Immediate Supervisor
Reason for Leaving
Do you have a 2nd Employer to add?*

YesNo
Employer
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Starting Position
Starting Salary
Last Position
Last Salary
Dates Employed
Duties
Immediate Supervisor
Reason for Leaving
Do you have an additional Employer to add?*

YesNo
Employer
Address
City/State/Zip
Starting Position
Starting Salary
Last Position
Last Salary
Dates Employed
Duties
Immediate Supervisor
Reason for Leaving
Do you have an additional Employer to add?*

YesNo
Employer
Address
City/State/Zip
Starting Position
Starting Salary
Last Position
Last Salary
Dates Employed
Duties
Immediate Supervisor
Reason for Leaving
HONORS, HONOR SOCIETIES AND/OR PROFESSIONAL SOCIETIES: EXCLUDE ORGANIZATIONS WHICH INDICATE RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, DISABILITY, OR VETERAN STATUS.
PROFESSIONAL LICENSES AND/OR CERTIFICATIONS
APPLICATION CERTIFICATION READ CAREFULLY BEFORE SIGNING

I certify that the information I have provided on this employment application (and accompanying resume, if any) is true and complete. I understand and agree that employment with Coastal Skin Surgery and Dermatology, if offered, may be immediately discontinued if misrepresentation, falsified statements, or material omissions are found to have been made. I authorize schools, former employers, and former supervisors to provide any and all information pertinent to my being considered for employment and hereby release those providing such information from any liability for doing so. I further understand that as a part of the procedure for my employment application, a background report(s) will be made concerning my Social Security Number, Criminal Record and/or Credit. If I am denied a job based either wholly or in part because of information contained in a background report, I will be provided the name and address of the reporting agency that supplied the information. I also understand that employment, if offered, is contingent upon my providing additional information for employee record purposes and also upon my providing proof of identity and employment eligibility and completing a Form I-9. I also understand that, if employed, Coastal Skin Surgery and Dermatology or I may terminate the employment relationship at any time, with or without cause, with or without notice, and that, if employed, employment does not constitute a contract of employment between myself and Coastal Skin Surgery and Dermatology. I will abide by and conform to all company policies, rules and procedures as may be in effect from time to time. I have read the above, understand its content and meaning, and agree to all of its provisions.

I understand that, upon my request, I will be provided a copy of my signed employment application.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Employment Application

Educational RecordPlease list school name, city and state, majore field of study and degree earned, if any: