Gateway Family Health Clinic Application for Employment

City

State

Zip

Name and location of high school

Diploma or equivalent received?

yes
no

Name and location of college or university

Degree Received

Major Subjects

GPA

No. of years completed

Name and location of college or university

Degree Received

Major Subjects

GPA

No. of years completed

Name and location of business/technical school

Degree, Diploma or Certificate Received

Major Subjects

GPA

No. of years completed

Employer 1

Address

Phone

Your name at that time

Date From
Date To

Type of Work

Job Title

Number of hours per week

Supervisor

Reason for Leaving

May we contact for reference?
yes
no

Primary job duties?

Employer 2

Address

Phone

Your name at that time

Date From
Date To

Type of Work

Job Title

Number of hours per week

Supervisor

Reason for Leaving

May we contact for reference?
yes
no

Primary job duties?

Employer 3

Address

Phone

Your name at that time

Date From
Date To

Type of Work

Job Title

Number of hours per week

Supervisor

Reason for Leaving

May we contact for reference?
yes
no

Primary job duties?

List 3 work/education related references who are in a position to evaluate your experience and qualifications.  Do not list relatives or personal friends.
.

Name
Occupation
Relationship
Number of years known

Company Name

Address

Work Telephone

Home Telephone

Name

Occupation

Relationship

Number of years known

Company Name

Address

Work Telephone

Home Telephone

Name

Occupation

Relationship

Number of years known

Company Name

Address

Work Telephone

Home Telephone

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

May we telephone you to follow up on this application at home?

no
yes

If yes, when is the best time to call?

May we telephone you to follow up on this application at work?

no
yes

If yes, when is the best time to call?

What is your business telephone number?

Please Read Carefully and Acknowledge Below

The facts set forth in my application for employment are true and complete.  I understand that if employed, any false statement on this application may result in my dismissal.  I further understand that this application is not and is not intended to be a contract of employment, nor does this application obligate the employer in any way if the employer decides to employ me.  I understand and agree that my employment is at-will and can be terminated by either party with or without notice, at any time, for any reason or no reason.  No one other than an officer of the Company has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing and then only in a writing signed by an officer.

I have read and understand the previous statement

Check to acknowledge