Name
Prior Names
Email
Soc Sec #
Address
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State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
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ME
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Zip
Home Phone
Business Phone
Position Apply For
Dates Available for Employment
Salary Desired
Are you willing to
Overtime (Over 40 hours per week)
Yes
No
Holidays
Yes
No
Rotating Shifts
Yes
No
On Call
Yes
No
Weekends (Saturday/Sunday)
Yes
No
Nights
Yes
No
Computer Skills - List applications you have experience with
Other Job Related Skills
Are you applying for
Full Time
Part Time
Flex Time
Temporary
How were you referred to this organization?
Have you ever been employed by this organization?
Yes No
If yes, position
Department
Start
End
Are you willing to provide necessary documentation to establish your identity and your authorization to work in the United States under Immigration Reform and Control Act of 1986?
Yes
No
After reviewing the essential functions of the job for which you are applying, are you able to perform these essential functions with or without an accommodation?
Yes
No
If you can perform the functions with an accommodation(s), please explain how you would perform the functions and with what accommodation(s):
Do you have any commitments to another employer that might affect your employment with us? Please explain:
Since reaching age 18, have you ever been convicted of a misdemeanor or felony? (Note: Convictions will not necessarily bar you from employment but are reviewed as related to the relevancy of the job for which you have applied)
Yes
No
If Yes, please explain:
Military Service
Yes
No
From
To
Branch of Service
Highest Rank Obtained
Additional Information
Please include any information you think would be helpful to use in considering you for employment, such as additional work experience, publication, activities, accomplishments, etc. (You may exclude all information indicative of age, sex, religion, color, national origin, or handicap.)
References
Please list references (not relatives or employers) to contact who are acquainted with your work history.
Name
Title/Occupation
Company/Address
Phone #
Education
Professional License/Certificate
Previous Experience
Please list name, address, and phone number of previous employers with most recent employer first. Periods of unemployment should be included.
Previous Employer 1
Previous Employer 2
Previous Employer 3
May we run an employment check from the employers listed above?
Yes
No
Has notice been given to present employer?
Yes
No
Is any additional information relative to change in name necessary to check your work history?
Yes
No
If yes, please explain
Remarks
I hereby affirm that the information provided on this application, (and accompanying resume, if any), is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.
I understand that my employment can be terminated, with or without cause, at any time at the discretion of the employer or myself. I understand that no management official of the employer, other than the chief administrative officer of the employer, has any authority to enter into any agreement contrary to the foregoing or to make any oral assurance or promise of continued employment to me.
I authorize person, schools, my current employee (if applicable), and previous employers and organizations named in this application (and accompanying resume, if any), to provide any relevant information that may be required to arrive at an employment decision.
Signature
Date
Fair Credit Reporting Act Consumer Report Disclosure
As required by the Fair Credit Reporting Act, this is to advise you that, in connection with your application for employment with CNOS, PC, a consumer report regarding your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living, may be obtained with respect to you for employment purposes for a consumer reporting agency. I hereby authorize CNOS, PC, to obtain and use a consumer report with respect to me for employment purposes.
Signature
Date
PLEASE READ CAREFULLY BEFORE SIGNING THIS APPLICATION
I authorize the Company to investigate all statements in this application and to secure any necessary information from all my employers and references. I hereby release all of those employers and references, and the Company from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for employment with the Company. I also authorize the Company to secure financial and credit information through an appropriate agency.
I understand that any offer of employment is contingent upon receipt of a satisfactory report concerning my credit, academic credentials, employment references, and, depending on the position offered, physical examination. I further understand that any false or misleading statements will be sufficient cause for rejection of my application if the Company has not employed me and for immediate dismissal if the Company has employed me. I also authorize the Company to supply information about my employment record, in whole or in part, in confidence to any prospective employer, government agency, or other party having a legal and proper interest, and I hereby release the Company from any and all liability for its providing this information.
In the event of my employment with the Company, I will comply with all rules, regulations, and policies set forth in the Company's policy manual or other communications distributed by the Company. I understand that nothing in this employment application, in the Company's policy statements or personnel guidelines or in my communications with any Company official is intended to create an employment contract between the Company and me. I also understand that the Company has the right to modify its policies without giving me any notice of the changes. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is biding upon the company unless it is made in writing and signed by a Company officer. I understand that if an employment relationship is established, I have the right to terminate my employment at any time for any reason. I also understand that the Company retains the right to terminate my employment at any time for any reason.
I hereby acknowledge that I have read and understand the preceding statement.
Signature
Date