aplication

West Texas Medical Associates

Application for Employment

*Position Applied for:
*Date of Application:
How did you learn about us?
If referred by other source:

Personal Information

*First Name:

*Last Name:

Middle Name:

*Address:

*City:

*State:

*Zip Code:

*Phone:

*E-Mail:

Social Security Number:

Date you can start:

Salary requirement:

Are you currently employed?

If so, may we contact your current employer?

Have you ever been employed with our company before?

When?

Have you been convicted of a felony within the past 5 years?

A criminal record does not automatically disqualify employment. It will be considered in relation to the position in which you are applying.

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Education

Type of school

Name and Address of School

Course of Study

Years Completed

Diploma / GED

High School / GED

Undergraduate College

Graduate / Professional

Other

List any professional licenses, registration, or certificates that you possess.

Type	State Issue	Expiration Date
1.
2.

Specialized Skills

Typing:

wpm

Computer Proficiency:

Proficient in Software:

Business Machines / Equipment

Other:

Other Qualifications

Summarize qualifications and other job-related skills that you possess from other employment or experience.

Describe any training, skills, or extra-curricular activities that may relate to the job
in which you are applying.

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Employment History

Begin with your present or last job. Please include any volunteer activities or military assignments. Please provide employment history up to at least 10 years including any period of unemployment.

Current / Most Recent Employer

Company:

Address:

Telephone Number(s)

Job Title:

Supervisor:

Reason for Leaving:

Date Employed:

From:

To:

Salary:

Beginning:

End:

Work Performed:

1st Previous

Company:

Address:

Telephone Number(s)

Job Title:

Supervisor:

Reason for Leaving

Date Employed:

From:

To:

Salary:

Beginning:

End:

Work Performed:

2nd Previous

Company:

Address:

Telephone Number(s)

Job Title:

Supervisor:

Reason for Leaving:

Date Employed:

From:

To:

Salary:

Beginning:

End:

Work Performed:

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3rd Previous

Company:

Address:

Telephone Number(s)

Job Title:

Supervisor:

Reason for Leaving:

Date Employed:

From:

To:

Salary:

Beginning:

End:

Work Performed:

4th Previous

Company:

Address:

Telephone Number(s)

Job Title:

Supervisor:

Reason for Leaving:

Date Employed:

From:

To:

Salary:

Beginning:

End:

Work Performed:

5th Previous

Company:

Address:

Telephone Number(s)

Job Title:

Supervisor:

Reason for Leaving:

Date Employed:

From:

To:

Salary:

Beginning:

End:

Work Performed:

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State any additional information that may be helpful in considering your application for employment.

References

Give the names of three persons that are not related to you, whom you have known at least one year.

Name	Address	Phone Number	Years Known

Authorization

" I certify that the facts contained in this application are true and complete to the best of my knowledge and I understand that, upon employment, falsified statements on this application shall be grounds for termination.

I authorize investigation of all statements contained in this application and the references and employers listed about to give you any and all information concerning my previous employment and any applicable information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

This application for employment will be considered active for a period of time not to exceed 1 year. Any applicant who wishes to be considered for employment beyond this specified time period should ask as to whether or not applications are being accepted at that time.

I understand and agree that if I am offered employment, my employment will be for a no definite term and that either I or the facility will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I further understand that this "at will" employment relationship may not be altered by any written document or by conduct unless an authorized executive of this organization specifically acknowledges such change in writing.

I also understand that I am required to abide by all the rules and regulations of the employer upon employment. "

* By checking this box and signing your intials below, you agree and understand the authorization statements above.

*Your intials

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