Submit an Application

Required*

    Personal Information

    Name*

    Address

    City, State, Zip

    Telephone*

    Email*

    May we contact you via email?*
    YesNo

    Employment Desired

    Position*

    Start Date*

    Desired Salary
    $

    Are you employed now?
    YesNo

    If so, may we contact your employer?
    YesNo

    Employer Name

    Employer Phone

    Have you applied to this company before?
    YesNo

    If so, when?

    Referred By

    Referrer's Phone

    Education

    High School

    Name

    Years Attended

    Did you graduate?
    YesNo

    Subjects Studied


    Trade or Correspondence School

    Name

    Years Attended

    Did you graduate?
    YesNo

    Subjects Studied


    College

    Name

    Years Attended

    Did you graduate?
    YesNo

    Subjects Studied

    References

    Please provide four (4) references not related to you, whom you have known at least one year.

    Reference 1

    Name

    Telephone

    Business

    Years Acquainted
    years


    Reference 2

    Name

    Telephone

    Business

    Years Acquainted
    years


    Reference 3

    Name

    Telephone

    Business

    Years Acquainted
    years


    Reference 4

    Name

    Telephone

    Business

    Years Acquainted
    years

    Employment Experience

    Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap or other protected status.

    Employer 1

    Employer

    Employed from

    Employed to

    Address

    City, State, Zip

    Phone

    Job Title

    Supervisor

    Reason for Leaving

    May we contact this employer?
    YesNo

    Work Performed


    Employer 2

    Employer

    Employed from

    Employed to

    Address

    City, State, Zip

    Phone

    Job Title

    Supervisor

    Reason for Leaving

    May we contact this employer?
    YesNo

    Work Performed


    Employer 3

    Employer

    Employed from

    Employed to

    Address

    City, State, Zip

    Phone

    Job Title

    Supervisor

    Reason for Leaving

    May we contact this employer?
    YesNo

    Work Performed

    Background Questionnaire

    Please tell me about your qualifications and skills for this position

    What did you like best about your last job?

    What motivated you to do an outstanding job?

    Why did you apply for this job?

    What did you least like about your last job?

    What are some of the problems you have encountered in working with supervisors, colleagues and/or clients and patients?

    Describe your short and long term goals?

    If you could design the ideal job for yourself, what would it be like?

    What accomplishments or projects are you most proud of?

    What characteristics about yourself do you like best?

    Disclosure and Authorization*

    I hereby authorize Clinic Service Corporation to investigate my background and qualifications for purposes of evaluating whether I am qualified for the position for which I am applying. I understand that Clinic Service Corporation will utilize an outside firm or firms to assist it in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company’s choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for employment will not be processed further.

    I authorize Clinic Service to perform a background/qualification check

    Authorization for Background Check*

    This is to notify you that we will be doing reference checks from your prior employers. We will verify dates of employment, position or title, your job duties and reason for leaving. By signing this form, you authorize us to call your previous employers and confirm this information.

    I authorize Clinic Service to confirm this information