Veterinary Medicine Employment Application Form
Applicant Information:
Applicant Name Home Phone Other Email Address Current Address Number and street City State & Zip How were you referred to Company?
Employment Positions:
Position(s) applying for:
Are you applying for:
Temporary work such as summer or holiday work? [ ] Y or [ ] N Regular part-time work? [ ] Y or [ ] N Regular full-time work? Y [ ] or N [ ] What days and hours are you available for work? If applying for temporary work, when will you be available? If hired, on what date can you start working? Can you work on the weekends? [ ] Y or [ ] N Can you work evening? [ ] Y or [ ] N Are you available to work overtime? [ ] Y or [ ] N Salary desired:
Personal Information:
Have you ever applied to/worked for Company before? [ ] Y or [ ] N If yes, please explain (include date): Do you have any friends, relatives, or acquaintances working for Company? [ ] Y or [ ] N If yes, state name & relationship: If hired, would you have transportation to/from work? [ ] Y or [ ] N Are you over the age of 18? ) If under age 18, hire is subject to verification of minimum legal age.)
[ ] Y or [ ] N If hired, would you be able to present evidence of you U.S. citizenship or proof of your legal right to work in the United States? [ ] Y or [ ] N If hired, are you willing to submit to and pass a controlled substance text? [ ] Y or [ ] N Are you able to perform the essential functions of the job for which you are applying, either with/without reasonable accommodation? [ ] Y or [ ] N If no, describe the functions that cannot be performed Have you ever been convicted of a criminal offense (felony or misdemeanor)? [ ] Y or [ ] N If yes, please describe the crime - state nature of crime(s), when and where convicted and disposition of the case.
Education, Training and Experience, High School:
School name: School address: School city, state, zip: Number of years completed: Did you graduate? [ ] Y or [ ] N Degree / diploma earned:
College/ University:
School Name: School address: School city, state, zip: Number of years completed: Did you graduate? [ ] Y or [ ] N Degree / diploma earned:
Employment History:
Are you currently employed? [ ] Y or [ ] N If you are currently employed, may we contact your current employer? [ ] Y or [ ] N Below please describe past and present employment positions, dating back five years. Please account for all periods of unemployment. Even if you have attached a resume, this section must be completed. Name of Employer: Name of Supervisor: Telephone Number: Business Type: Address: City, state, zip: Length of employment (Include dates):
Position & Duties: Reason for leaving: May we contact this employer for references? [ ] Y or [ ] N
Name of employer: Name of supervisor: Telephone number: Business type: Address: City, state, zip: Length of employment (Include dates): Position & duties: Reason for leaving: May we contact this employer for references? [ ] Y or [ ] N
References
List below three persons who have knowledge of your work performance within the last four years. Please include professional references only. 1. Name- First, Last: ________________________
Telephone number: _________________ Address: _______________________ City, state, zip: _________________
Occupation: ____________________ Number of years acquainted: ____________________ 2. Name- First, Last: _____________________
Telephone number: ______________ Address: _______________ City, state, zip: ____________________ Occupation: ____________________ Number of years acquainted: ____________________ 3. Name- First, Last: ________________________
Telephone number: ____________________ Address: ___________________ City, state, zip: _______________________ Occupation: _________________________ Number of years acquainted: ________________________ Please Read and Initial Each Paragraph, then Sign Below I certify that I have not purposely withheld any information that might adversely affect my chance for hiring. I attest to the fact that the answers given by me are true & correct to the best of my knowledge and ability. I understand that any omission (including and misstatement) of material fact in this application or on any document used to secure can be grounds for reje ction of application or, if I am employed by this company, terms for my immediate expulsion from the company.
I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or the company.
I permit the company to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work recorded an d my professional
experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers, and all other persons, corporations, partnerships, and associates from any and all claims, demands, or liab ilities arising out of or in any way related to such examination or revelation.
Applicants Signature: ________________________________ Date: _______________________________________
