Application For Employment at Eastern Dermatology and Pathology

Eastern Dermatology and Pathology considers all applicants for all positions without regard to race, color, religion,

creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

Position(s) Applied For:

Date of Application:

How Did You Learn About Eastern Dermatology and Pathology?

Advertisement         Friend         Inquiry        Employment Agency           Relative      Other:

Last Name:

First Name:

Middle Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Home Telephone Number:

Business Telephone Number:

Best time to contact you at home is:

If you are under 18 years of age, can you provide required proof of your eligibility to work?

Have you ever filed an application or submitted a resume to us before?

If yes, give date:

Have you ever been employed with us before?

Do any of your friends or relatives, other than spouse, work here?

                        If yes, state name:
                        relationship:
                        and location:

Are you currently employed?

May we contact your present employer?

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

                        Proof of citizenship or immigration status will be required upon employment.

  AM PM

Yes            No

Yes            No

Yes            No

Yes            No

Yes            No

Yes            No

Yes            No

Date available to work:

Are you available to work:        Full Time

                                                Part Time

                                                Temporary

What is your desired salary range?

(Please indicate: 1  2  3 shift)

(Please indicate: Mornings  Afternoons  Evenings)

(Please indicate dates available: - )

Are you currently on “lay-off” status and subject to recall?

Can you travel if a job requires it?

Yes            No

Yes            No

Education:

School:

Name and Address of School:

Course of Study:

Years Completed:

Diploma / Degree

High School

Undergraduate College

Graduate / Professional

Other (Specify)

Additional Information:

State any additional information you feel may be helpful to us in considering your application.

Work Experience:

Start with your present or last job. Include any job-related military service assignments and volunteer activities. Exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.

Employer #1

Employer:

Dates Employed:

Work Performed:

Address:

From:

To:

Telephone Number(s):

Starting / Present Job Title:

Hourly Rate / Salary:

Supervisor:

Starting:

Final:

Reason for Leaving:

May We Contact:   Yes No

Employer #2

Employer:

Dates Employed:

Work Performed:

Address:

From:

To:

Telephone Number(s):

Starting / Present Job Title:

Hourly Rate / Salary:

Supervisor:

Starting:

Final:

Reason for Leaving:

May We Contact:    Yes No

Employer #3

Employer:

Dates Employed:

Work Performed:

Address:

From:

To:

Telephone Number(s):

Starting / Present Job Title:

Hourly Rate / Salary:

Supervisor:

Starting:

Final:

Reason for Leaving:

May We Contact:    Yes No

Personal / Professional References:

Do not include family members or past supervisors.

Name:

Phone Number:

Best Time to Call:

Occupation:

1.

2.

3.

Applicant’s Statement:

I certify that answers given herein are true and complete.

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 Eastern Dermatology and Pathology is of an “at will” nature, which means that the Employee may resign at any time and Eastern Dermatology and Pathology 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 Eastern Dermatology and Pathology.

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 Eastern Dermatology and Pathology.

By clicking the submit button, you are electronically signing this employment application.