JT - Application for Employment

Employment History
Please provide all employment information for your past four employers starting with the most recent.
Employer:*
Position Held:*
Address:*
Telephone #:*
Immediate Supervisor and Title:*
Dates Employed: From*

MonthDayYear
Date
Dates Employed: To*

MonthDayYear
Date
Salary:*
Job Summary:*
Reason for Leaving:*
Employer:
Position Held:
Address:
Telephone #:
Immediate Supervisor and Title:
Dates Employed: From

MonthDayYear
Date
Dates Employed: To

MonthDayYear
Date
Salary:
Job Summary:
Reason for Leaving:
Employer:
Position Held:
Address:
Telephone #:
Immediate Supervisor and Title:
Dates Employed: From

MonthDayYear
Date
Dates Employed: To

MonthDayYear
Date
Salary:
Job Summary:
Reason for Leaving:
Employer:
Position Held:
Address:
Telephone #:
Immediate Supervisor and Title:
Dates Employed: From

MonthDayYear
Date
Dates Employed: To

MonthDayYear
Date
Salary:
Job Summary:
Reason for Leaving:

Other Skills and Qualifications
Summarize and job-related training, skills, licenses, certificates, and/or other qualifications:*
Educational History
List school name and location, years completed, course of study, and any degrees earned:*
References

List 3 references' names, telephone numbers, relationship (ex. coworker, supervisor, friend, etc.) and years known (do not include relatives or employers already listed):*

	Name	Telephone#:	Years Known:
1
2
3

I hereby authorize Classen Urgent Care/Classen Family Practice to contact, obtain, and verify the accuracy of information contained in this application from all current and previous employers, educational institutions, references and background check. I also hereby release from liability Classen Urgent Care/Classen Family Practice and it’s representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specific length of employment, and that this application does not constitute an agreement or contract for employment. Accordingly, either I or Classen Urgent Care/Classen Family Practice can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I understand that it is the policy of this organization not to refuse or hire to hire or otherwise discriminate against a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA.

I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit proof within the required time shall result in immediate termination of employment.

I represent and warrant that I have read and understand the foregoing, and that I seek employment under these conditions.
Applicant signature*
Date

MonthDayYear
Date
Attach Resume

Cancelof
Address:
Street, City, State, Zip
Should be Empty:

Employment History