Application Form For Employment

ALL POTENTIAL EMPLOYEES ARE EVALUATED WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, AGE, MARITAL OR VETERAN STATUS, THE PRESENCE OF A NON-JOB RELATED HANDICAP OR ANY OTHER LEGALLY PROTECTED STATUS.

DEMOGRAPHIC INFORMATION:

Name *

First

Middle

Last

Social Security #

Date Of Birth *

If under 18, please list age:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone Number:

Office Phone
Cellphone
or others

Email Address *

Email

Confirm Email

AVAILABILITY:

What date would you be available to start working?

Desired Wage/Salary $

Employment desired?

Full Time
Part Time
Either
PRN

Days/Hours available to work

NO PREFERENCE

Are you authorized to work in the U.S. for any employer, without restrictions?

Yes
No

Have you ever been convicted of a felony?

Yes
No

If yes, describe circumstances:

If selected for employment, are you willing to submit to a pre‐employment drug screening test?

Yes
No

Do you have an active Driver’s License?

Yes
No

Do you have a dependable transportation to work?

Yes
No

License Details *

First

Middle

Last

Have you ever been in the armed forces?

Yes
No

Are you currently a member of the National Guard?

Yes
No

First

Middle

Last

Have you worked for Southeast Lung in the past?

Yes
No

EDUCATION: (list all prior education)

High School:

Name Of School *

Address

Address Line 1

Address Line 2

City

State

Zip Code

First

Last

Specify the name you used at graduation (if different from name listed above):

College/University:

Name of School *

Address

Address Line 1

Address Line 2

City

State

Zip Code

First

Last

Specify the name you used at graduation (if different from name listed above):

Business or Trade School:

Name of School: _

Address

Address Line 1

Address Line 2

City

State

Zip Code

First

Last

Specify the name you used at graduation (if different from name listed above):

Professional School:

Name of School:

Address

Address Line 1

Address Line 2

City

State

Zip Code

First

Last

Specify the name you used at graduation (if different from name listed above):

Are you a certified Texas Surgical Assistant?

Yes
No

List any other training, certifications, or licenses held:

List other information pertinent to the employment you are seeking:

EMPLOYMENT (list all previous employer over the past 7 years)

(Most Recent First)

1. Employer Details

First

Last

Employment Start Date (mm/yyyy):

Employment End Date (mm/yyyy):

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Direct Supervisor (list full name):

Duties Performed:

Salary: $

Reason for Leaving

If you are still employed, may we contact this employer at this time?

Yes
No

2. Employer Details

First

Last

Employment Start Date (mm/yyyy):

Employment End Date (mm/yyyy):

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Direct Supervisor (list full name):

Salary: $

Reason for Leaving

If you are still employed, may we contact this employer at this time?

Yes
No

3. Employer Details

First

Last

Employment Start Date (mm/yyyy):

Employment End Date (mm/yyyy):

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Direct Supervisor (list full name):

Salary: $

Reason for Leaving

If you are still employed, may we contact this employer at this time?

Yes
No

REFERENCES: (list three business references we may contact to learn about your general reputation)

1.

First

Last

First

Last

2.

First

Last

First

Last

3.

First

Last

First

Last

ACKNOWLEDGMENT AND AUTHORIZATION

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 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.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer

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Click or drag a file to this area to upload.

Date