Job Application

In compliance with applicable laws, this facility does not discriminate because of age, sex, race, color, religion, marital status, national origin, veteran status, or disability.
Position Applied for:
Shift Preferences, if applicable
Status Preferred

Full Time Part Time Pool
Who referred you to our facility?
Minimum Salary Requirement
Have you ever worked for this facility before?

Yes No
If yes, when?
Have you ever applied to this facility before?

Yes No
If yes, when?
Date you will be available if your application is accepted:

Employment History
As a part of our normal procedure for processing applications, a routine inquiry may be made concerning information on an applicant’s work and educational history. In compliance with the Fair Credit Reporting Act, further information of the nature and scope of such inquiry, if one is made, is available to you upon written request. All employment should be covered below including jobs held while in school or in the military.

Record your present or last position first and list back in chronological order.
Employer Name *
Start Date *
End Date *

Employer Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Position(s) Held: *
Starting Salary
Ending Salary
Briefly explain your duties, responsibilities, and number of people you supervised in each position: *
Why did you leave? *
Supervisor Name *

First Name Last Name
Supervisor Title: *
Supervisor Phone Number *

- Area Code Phone Number
May we contact this person? *

Yes No
______________________________________________________________________________________
Employer Name
Start Date
End Date

Employer Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Position(s) Held:
Starting Salary
Ending Salary
Briefly explain your duties, responsibilities, and number of people you supervised in each position:
Why did you leave?
Supervisor Name

First Name Last Name
Supervisor Title:
Supervisor Phone Number

- Area Code Phone Number
May we contact this person?

Yes No
______________________________________________________________________________________
Employer Name
Start Date
End Date

Employer Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Position(s) Held:
Starting Salary
Ending Salary
Briefly explain your duties, responsibilities, and number of people you supervised in each position:
Why did you leave?
Supervisor Name

First Name Last Name
Supervisor Title:
Supervisor Phone Number

- Area Code Phone Number
May we contact this person?

Yes No
______________________________________________________________________________________
Employer Name
Start Date
End Date

Employer Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Position(s) Held:
Starting Salary
Ending Salary
Briefly explain your duties, responsibilities, and number of people you supervised in each position:
Why did you leave?
Supervisor Name

First Name Last Name
Supervisor Title:
Supervisor Phone Number

- Area Code Phone Number
May we contact this person?

Yes No

Please list current memberships in civic, professional, or other organizations:
This space is provided for you to briefly summarize any additional qualifications you feel important in considering your application for employment:
Please upload a copy of your resume. PDF and Word Documents are preferred.
I certify that the information contained in this application is correct to the best of my knowledge and understand that falsification of this information is grounds for dismissal. I authorize an inquiry to be made on the information contained in this application, and authorize any individual contacted during this inquiry to give you any and all information concerning my previous employment and any pertinent information that may have, personal or otherwise, and release all parties from all liability for any damage that my result from furnishing same to you. I agree that Surgery Center at Pelham may obtain an investigative consumer report on me. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.

If an employment relationship is established, I agree to conform to the rules and regulations of Surgery Center at Pelham and my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either the Facility or myself. I also understand that any period of employment is not for a specific duration and understand that with the exception of the Administrator of Surgery Center at Pelham no facility representative has the authority to make any oral or written agreements which are contrary to the foregoing.

By checking the box below, I certify that I have read, understand and agree to the above.
*

I agree to the above statements.
Should be Empty:

	Type	State	Renewal Date	Expiration Date
1
2
3

General Information

Employment History

Education Information