APPLICATION FOR EMPLOYMENT

(PRE-EMPLOYMENT QUESTIONAIRE-PLEASE PRINT)

ALL APPLICANTS ARE CONSIDERED WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, MARITAL OR VETERAN STATUS, PHYSICAL OR MENTAL DISABILITY, OR ANY OTHER LEGALLY PROTECTED STATUS. I understand that employment is contingent upon a negative drug screen and an acceptable background check, and that I am not guaranteed employment.

Last Name First Middle Date of Application

Present Address –Street City State Zip

Permanent Address –Street City State Zip

Phone Number –Home Phone Number –Cell Social Security Number

Position Desired: ☐Full Time ☐Part Time

Date You Can Start Salary Desired Are you employed now? May we contact your employer?

☐Yes ☐No ☐Yes ☐No

Have you been employed here previously? ☐Yes ☐No Have you ever applied here before? ☐Yes ☐No

If you answered “yes” to either of the above, state when and where you applied and/or worked.

Are you capable of performing the essential functions of this position as they have been outlined? ☐Yes ☐No

If not, you should advise us of what function(s) you cannot perform and whether you believe you require an accommodation in order to perform the function(s).

Do you have the ability, with or without reasonable accommodations, to work overtime or to travel if travel and/or overtime are required by the job for which you are applying? ☐Yes ☐No

Have you ever served in the Military? ☐Yes ☐No Are you 18 years or older? ☐Yes ☐No

Are you a citizen of the United States or authorized to work in the United States? ☐Yes ☐No

What languages, other than English do you speak?

Have you ever pled guilty, no contest, or been found guilty of a crime? ☐Yes ☐No

List all felonies and misdemeanors, including DUl's, DWI's and drug crimes. Include all minor traffic tickets if the job for which you are applying requires that you drive a company owned vehicle. A "Yes" answer will not automatically disqualify an applicant from being considered as a candidate for employment; the nature and date of the crime and relation to specific job requirements will be considered.

Have you ever been fired from any job for any reason, or did you quit before or after being told you would be fired?

☐Yes ☐No If yes, please explain.

Education

Name and Locations / Address / Major Course Subject / Circle Last Year Completed / Graduated?
Yes, No, GED / Degree
High School
Technical School
College
Other

Employment Experience

Start Date / End Date / Employer / Phone / Position / Reason for Leaving

List any friends or relatives currently working for Premier Pediatrics and Adolescent Care.

References

Name / Address / Phone / Business / Years Acquainted