Name*

Address

City, State, Zip

Telephone*

Email*

May we contact you via email?*

YesNo

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

High School

Name

Years Attended

—Please choose an option—123456

Did you graduate?

YesNo

Subjects Studied

Trade or Correspondence School

Name

Years Attended

—Please choose an option—123456

Did you graduate?

YesNo

Subjects Studied

College

Name

Years Attended

—Please choose an option—123456

Did you graduate?

YesNo

Subjects Studied

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

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

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?

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

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