Application for Employment First Name:*Middle Name:Last Name:* Social Security Number: Present Address:* Present City:* Present State:* Present Zip:* Permanent Address:* Permanent City:* Permanent State:* Permanent Zip:* Phone:* Email:* Name In Case of Emergency: Address In Case of Emergency: Phone In Case of Emergency: Are You 18 or Older? Yes No Are You Either A U.S. Citizen or An Alien Authorized To Work in the United States? Yes No School Name of School and Location No. of Years Attended Course of Study Did You Graduate? Diploma or Degree High Schoolor GED College Trade Graduate Professional Please List Professional Licenses, Certificates, or Permits Held Number: Has your license ever been suspended or revoked in any state? Yes No If yes, please explain: Please list any technical trade or medical skills: (Typing, WPM, Word Processing, Knowledge of Medical Terminology, Computers, CRT, 10 Key Calculator) Position: Source of Referral: Applying for: Full Time Part Time Temporary Occasional Name and address of employer Start date Leaving date Weekly starting salary Weekly final salary Job title May we contact supervisor? Name and title of supervisor Phone number Description of work Reason for leaving Name and address of employer Start date Leaving date Weekly starting salary Weekly final salary Job title May we contact supervisor? Name and title of supervisor Phone number Description of work Reason for leaving Name and address of employer Start date Leaving date Weekly starting salary Weekly final salary Job title May we contact supervisor? Name and title of supervisor Phone number Description of work Reason for leaving Name and address of employer Start date Leaving date Weekly starting salary Weekly final salary Job title May we contact supervisor? Name and title of supervisor Phone number Description of work Reason for leaving Give below the names of three people not related to you, whom you have known at least one year. Name Address Business Telephone Years Branch of Service: Discharge date: Present membership in National Guard or Reserve: Date obligation ends: Type of duty and special training that may be related to the job you are applying: Were you honorably discharged? Yes No If no, please explain: Do you have any limitations that would preclude you from performing the essential functions of the job for which you are being considered? Yes No Are there any accommodations Longmont Surgery Center could make? Yes No If yes, please explain: Have you ever been seriously injured? Yes No Give details: What foreign languages do you speeak fluently?Read Write Have you ever been invloved in a medical malpractice case in this or any other state? Yes No If yes, please explain: Have you ever been convicted of a felony or misdemeanor? Yes No If yes, please explain: You will not be denied employment solely because of a conviction record, unless the offense if related to the job for which you have applied. I understand and agree that if a job offer is made to me, I may be required consistent with legal and business reasons to take one or more specified tests (i.e. physical examinations, etc.) as a condition of hire or continued employment. I agree to take such test(s) at such time as designated by the company and to release the company, its doctors, officers, agents or employees from any claim arising in connection with the use of such test(s). Yes No "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for immediate dismissal even if they were not known by Longmont Surgery Center at the time. I authorize investigation of all statements contained herein, the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release all parties from liability for any damage that may result from furnishing same to you. I understand that any employment is contingent upon successful completion of all employment tests and employment forms. I understand and agree that, if hired, my employment is for no definite period and no guaranteed number of hours, and may, regardless of the date of payment of my wages and salary, be terminated at any time without any prior notice." Signature: Application sent successfully Application failed to sendPlease try again or contact.
