This facility receives applications and employs persons without regard to race, color, sex, religion, age, national origin, physical or mental disability, marital status, veterans’ status, citizenship status or any other category protected by local, state or federal law. In addition this facility makes reasonable accommodation to the needs of disabled applicants and employees, so long as this does not create an undue hardship on the surgical center or threaten the health or safety of others at work. The receipt of this application does not mean that job openings exist at our surgery center and does not obligate us in any way. We appreciate your interest in our facility.

Personal Information

Last First Middle NAME:

Date of Birth:

SOCIAL SECURITY NO:

Street City State Zip ADDRESS:

Your Email:

If hired, can you furnish proof of age? YESNO

If hired, can you furnish proof that you are legally entitled to work in the U.S.? YESNO

Can you perform the essential functions of the job, with or without reasonable accommodation? YESNO

AVAILABILITY

I am applying for the following position:

Desired Pay:

Date available for work:

Type of Employment Desired: Full-TimePart-TimeTemporary

I am applying for the following position:

Would you consider working: Weekends & HolidaysRotating ShiftsOn CallAny Shift

MISCELLANEOUS

Have you ever been convicted of a felony? YESNO

If yes, please explain. (Such a conviction may be relevant if job-related, but does not necessarily bar you from employment.)

EDUCATION: Type the following info for each:
Schools Attended (include current) | City - State | Years Completed | Diploma/Degree

High School:

College or University:

Other:

Scholastic Honors, Scholarships, etc.:

Do you have any other experience, training, qualifications, or skills which would apply to the position for which you are applying?
Please list:

PROFESSIONAL LICENSES AND/OR CERTIFICATIONS
Type State Issued Date Number

EMPLOYMENT HISTORY

Please list your employment record, including any periods of unemployment. Begin with your most recent employer. If you were employed under another name, please enter under the company name. Attach a resume only to supplement the information below. This application form must be completely filled out.

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Company Name

Company Address

Telephone

Name of Supervisor

Employed (month and year) From To

Salary/Hourly Rate:

State job title, nature of work performed, and job responsibilities

Reason for Leaving:

May we contact this employer?: YESNO

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Company Name

Company Address

Telephone

Name of Supervisor

Employed (month and year) From To

Salary/Hourly Rate:

State job title, nature of work performed, and job responsibilities

Reason for Leaving:

May we contact this employer?: YESNO

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Company Name

Company Address

Telephone

Name of Supervisor

Employed (month and year) From To

Salary/Hourly Rate:

State job title, nature of work performed, and job responsibilities

Reason for Leaving:

May we contact this employer?: YESNO

REFERENCES

List business or educational references of three non-relatives who are qualified to evaluate your education or work experience.

I hereby state that the information given by me in this application is true in all respects. I understand that any material misrepresentation or deliberate omission of fact in my application may be justification for refusal of employment, or if employed cause me to be subject to dismissal without notice at any time.
I understand that employment at the surgery center is on an at will basis and that employment is not offered, contracted or guaranteed for any specific period of time. I understand that employment may be terminated by either party at any time, with or without cause, and with or without notice.
I agree to search of my person or of any locker or property assigned to me, and hereby waive all claims for damages on account of such examination.
I authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the duties of a job I am being considered for prior to employment or in the future during my employment with this ASC. I understand that my employment is dependent upon my passing a physical exam.
I understand that business needs may make the following conditions mandatory; overtime, shift work, or a work schedule other than Monday through Friday.
It is my understanding that this ASC may make a thorough investigation of my entire work and personal history and may verify all data given in my application for employment, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by this ASC and I release from liability any person giving or receiving such information.
I understand that this is an application for employment and that no employment contract is being offered.
I understand that if I am employed, such employment is for an indefinite period of time and that this ASC can change wages, benefits and conditions at any time.
A basic part of medical ethics is that all information concerning patients (their conditions, treatment and financial information), their doctors and your fellow employees, as well as personal information concerning bonuses and or pay raises remain strictly confidential, any violation of confidentiality could result in discharge.
I have read, understand, and agree to the above.

APPLICANTS SIGNATURE (use your mouse to sign in the box below):