Texas Osteopathic Medical Association (Toma) Employment Application

TEXAS OSTEOPATHIC MEDICAL ASSOCIATION (TOMA) EMPLOYMENT APPLICATION

Texas Osteopathic Medical Association

1415 Lavaca Street

Austin, TX 78701

512-708-8662 (F) 512-708-1415

The Texas Osteopathic Medical Association is an Equal Opportunity Employer and considers all applicants for employment without regard to race, color, religion, sex, sexual orientation, national origin, mental or physical disability, status as a veteran or any other protected class in accordance with federal, state and local laws.

Please print using Blue or Black Ink

Name: / Date of Application
Address Street City State Zip / Phone
Permanent Address if different from above / Alternate Phone
Position Applying for: / Available Date

Full Time Part Time

If required, are you willing to work hours other than 8:00 a.m. - 5:00 p.m. Monday through Friday? Yes No

Are you willing to work weekends? Yes No

Are you over the age of 18? Yes No

Do you have the legal right to work and remain in the United States? Yes No

Federal law requires that employers hire only individuals who are authorized to be lawfully in the United States. In compliance with such laws, the Texas Osteopathic Medical Association will verify the status of every individual offered employment. In this connection, all offers of employment are subject to verification of the applicant’s identity and employment authorization, and it will be necessary for applicants to submit all documents as are required by law to verify your identification and employment authorization.

Have you ever been employed by TOMA before? Yes No If yes, when? ______to ______

How did you hear of this position? ______

Do you have a friend or relative working for TOMA? Yes No If so, who and where? ______

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DRIVING INFORMATION

If you are applying for a position that requires driving a rental vehicle or your personal vehicle on Company business, complete this section. List all states in which you have a driver’s license.

STATELICENSE NO.TYPE EXPIRATION DATE

______

Have you ever been convicted of any (state or federal) felony criminal offense or a misdemeanor criminal offense involving moral turpitude? (Exclude convictions that have been sealed, expunged or legally eradicated Yes No

If yes, fully explain: ______

______

“Convicted means pled guilty or no contest, found guilty by judge or jury, placed on community supervision (“probation”), deferred adjudication or pretrial diversion. “Moral turpitude” means crimes involving theft, fraud, deception, assault, sex crimes , or drug trafficking or possession.

At this time have you been arrested, indicted, or otherwise charged, or are you out on bail, the subject of a current warrant for arrest, or released on your own recognizance pending trial? Yes No

If yes, fully explain: ______

______

TOMA will not automatically deny employment due to a criminal conviction, arrest, or pending charge, but will consider the nature and gravity of the offense for which the conviction, arrest or charge occurred, whether it is job related or when it occurred.

RECORD OF EDUCATION
Establishment / Name and Address of Establishment / Course of Study / Year Began / # of Years Completed / Did you graduate? / Diploma or Degree
High School
College
Graduate
Other
EMPLOYMENT EXPERIENCE
Start with your present or last job and include all employment for the past ten years. Include military service assignments and volunteer activities. If you need additional space, please continue on a separate sheet of paper.
Employer – Phone # / Dates Employed
From: To: / Work Performed
Address
Title
Supervisor
Reason for Leaving
Employer – Phone # / Dates Employed
From: To: / Work Performed
Address
Title
Supervisor
Reason for Leaving
Employer – Phone # / Dates Employed
From: To: / Work Performed
Address
Title
Supervisor
Reason for Leaving
Employer – Phone # / Dates Employed
From: To: / Work Performed
Address
Title
Supervisor
Reason for Leaving
Employer – Phone # / Dates Employed
From: To: / Work Performed
Address
Title
Supervisor
Reason for Leaving
SPECIAL SKILLS AND QUALIFICATIONS

Summarize your special skills and qualifications acquired from employment or other experiences: ______

______

Current Licenses/Certifications/Registrations and dates received (please attach copies)

______

______

______

Subjects of Special Study or Research: ______

______

Volunteer Experience: ______

______

EMPLOYMENT REFERENCES
Name / Address
Phone / Length Known
Name / Address
Phone / Length Known
Name / Address
Phone / Length Known

STATEMENTS

I hereby certify that the foregoing statements as well as those on any attachments to this form are true and correct to the best of my knowledge and are given of my own free will. I agree that any misstatements or misrepresenta-

tions as to material facts will constitute grounds for unfavorable consideration or dismissal from employment. Any falsification on the application will immediate grounds fortermination. I understand that references will be checked and that all offers of employment are contingent on the results of a pre-employment criminal background check and/or pre-employment drug screen. I understand that the Texas Osteopathic Medical Association is an “At Will Employer” governed by the Right to Work laws in the State of Texas; and if employed I may be separated from employment with TOMA at any time.

I agree that, if I am hired, I will conform with all company policies and procedures and understand that TOMA may modify, amend and/or revoke any of its employment policies, practices and benefits without prior notice or my consent.
I understand that if I am hired, I may be required at any time to submit to a drug test, alcohol test and/or medical examination, to extent permitted by law, conducted by a licensed physician selected by TOMA at TOMA expense. I hereby give a continuing authorization to any hospital or other health care facility and to any physician or other person conducting such medical examinations and/or tests to furnish to TOMA or its designated agent, any medical records or medical information resulting from such examinations and/or tests. I further authorize the release to TOMA of such medical records and medical information as may be relevant and necessary to the disposition or investigation of any claim against the Company or the insurance carriers of the Company, including any claim I may have for worker’s compensation.
I understand that TOMA reserves the right to use any method of investigation which, in its sole discretion, it deems reasonable and necessary to determine whether any employee has engaged in conduct warranting disciplinary action. As a condition of employment, if hired, I agree to cooperate in any such investigation.
I understand that TOMA may investigate my work and personal history. I authorize all persons, schools, companies, corporations, credit bureaus and law enforcement agencies to supply any information concerning my background and release them from any liability and responsibility from their doing so. I also authorize the Company to provide truthful information concerning my employment with the Company to future prospective employers and I agree to hold the Company harmless for providing such information.

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Signature of ApplicantDate