Employment Application 2.4

Employment Application
Personal Data
Name*

First NameLast Name
Prefix
Suffix
Present Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address
Personal email
If hired, can you provide the documents to prove that you are authorized to work in the U.S.*

YesNo
Are you 18 years or older?*

YesNo
Date of Birth

MonthDayYear
Date
What position are you applying for*
Do you want to work*

Full TimePart Time
Days Available*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Hours Available
Desired location(pick all that apply)

CaryClaytonHolly SpringsRaleighRolesvilleWake ForestWest Cary
Desired salary*
Date available for work*

MonthDayYear
Date
Name of College, University, or Voc-Tech attended
Are you currently a student

YesNo
Have you or an immediate family member ever been employed by JMA Pediatrics*

YesNo
Have you or an immediate family member ever been a patient of JMA Pediatrics*

YesNo
Professional Qualifications
Select Highest Levels Completed
High School
College/Tech
Credentials
NC Certificate Number
Year of Expiration
Renewal License Number
If yes, please explain:
If yes, please explain:
Work Experience
Employer:
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Started

MonthDayYear
Date
Date Ended

MonthDayYear
Date
Name of Immediate Supervisor
Reason For Leaving
If currently employed may we contact your current employer?

YesNo
Employer:
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Started

MonthDayYear
Date
Date Ended

MonthDayYear
Date
Name of Immediate Supervisor
Reason For Leaving
If currently employed may we contact your current employer?

YesNo
Employer:
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Started

MonthDayYear
Date
Date Ended

MonthDayYear
Date
Name of Immediate Supervisor
Reason For Leaving
Professional References
Name: Title
Organization:
Phone Number
Please enter a valid phone number.
Date Started

MonthDayYear
Date
Date Ended
MM-DD-YYY
May we contact this professional reference?*

YesNo
Name: Title
Organization:
Phone Number
Please enter a valid phone number.
Date Started

MonthDayYear
Date
Date Ended
MM-DD-YYY
May we contact this professional reference?*

YesNo
Name: Title
Organization:
Phone Number
Please enter a valid phone number.
Date Started

MonthDayYear
Date
Date Ended
MM-DD-YYY
May we contact this professional reference?*

YesNo
Please Read Carefully
I understand that the employer follows an employment-at-will policy in that the employer or I may terminate my employment at any time or for any reason consistent with applicable state or federal law. I understand that to be employed I must be lawfully authorized to work in the United States, and I must show the employer documents that will prove this.

I understand that the company will thoroughly investigate my work and personal history and verify all data given on this application, on related papers, and in interviews. I authorize all individuals, schools, and firms named therein, except my current employer if so noted, to provide any information requested about me, and I release them from all liability for damage in providing this information. Any applicable patient history with the company obtained is requested to ensure appropriate access controls and compliance with patient confidentiality standards.

I certify that all statements herein are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal of employment.

This application for employment shall be considered active for a period of time not to exceed thirty (30) days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.
Today's Date*

MonthDayYear
Date
Signature First Name Last Name
Should be Empty:

Employment Application

Personal Data

Professional Qualifications

Work Experience

Professional References

Please Read Carefully