EMPLOYMENT APPLICATION

Please complete the entire application.
1. Employer Information
Employer: The Center for Bone and Joint Disease

Address: 7544 JacqueRd

City/State/ZIP: Hudson, Florida 34667

Telephone: 727-697-2200

It is the policy of The Center for Bone and Joint Disease to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age ,disability or veteran status.
2. Applicant Information
Applicant Full Name:
Home Address:
City/State/ZIP:
Number of years at this address:
Mobile phone:
Home phone:
Social Security Number:
Driver's License (State/Number):

3. Emergency Contact
Who should be contacted if you are involved in an emergency?
Contact Name:
Relationship to you
Address:
City/State/ZIP:
Day time phone:
Evening phone:
4. Job Position Applied For:
Full or Part Time?
5. Salary Desired:
$ per
6. Who referred you to our company?
7. Do you have any friends or relatives who work here?
- Yes
- No
If yes, please list here:
8. Are you at least 18 years old?
- Yes
- No

9. If you are offered employment, when would you be available to begin work ?
10. Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation?
- Yes
- No
If no, what reasonable accommodation, if any, would you request?
11. Have you ever been convicted of a crime? A back ground check is required for all final candidates prior to employment start date.
- No
- Yes
Please give the details of your conviction; including date, location and nature of conviction.
THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.
12. List any skills that may be useful for the job you are seeking, including the number of years of experience.

13. Applicant Employment History (if resume attached, please skip Qu.13 & 14)
List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment. If additional space is needed, continue on the back page of this application.
Employer Name:
Supervisor Name:
Address:
City/State/ZIP:
Job Duties:
Reason for Leaving:
Dates of Employment (Month/Year):
Employer Name:
Supervisor Name:
Address:
City/State/ZIP:
Job Duties:
Reason for Leaving:
Dates of Employment (Month/Year):

Employer Name:
Supervisor Name:
Address:
City/State/ZIP:
Job Duties:
Reason for Leaving:
Dates of Employment (Month/Year):
14. Applicant's Education and Training
College/University
Name and Address
Did you receive a degree?
- Yes
- No
If yes, degree(s) received:
High School/GED
Name and Address
Did you receive a degree?
- Yes
- No
Other Training (graduate, technical, vocational):
Please indicate any current professional licenses or certifications that you hold:

15. References
List any two non-relatives who would be willing to provide a reference for you.
Name:
Address:
City/State/ZIP:
Telephone:
Relationship:
Name:
Address:
City/State/ZIP:
Telephone:
Relationship:

CERTIFICATION
I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences immediate termination.

I authorize The Center for Bone and Joint Disease to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Practice Administrator, the employment relationship will be" at - will. “In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of The Center for Bone and Joint Disease, except in a specific written contract of employment signed on behalf of the organization by its Practice Administrator, has the power to alter or vary the voluntary nature of the employment relationship.

The Center for Bone and Joint Disease is a Drug-Free Workplace. All applicants considered final candidates for a position will be tested for drugs are part of the application process. Any applicant who refuses to submit to the pre-employment drug test will be ineligible for hire.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.
APPLICANT SIGNATURE
DATE
Date Format: MM slash DD slash YYYY

Step 1 of 7

1. Employer Information

2. Applicant Information

3. Emergency Contact

13. Applicant Employment History (if resume attached, please skip Qu.13 & 14)

14. Applicant's Education and Training

15. References

CERTIFICATION