Application for Employment
Please complete all sections of this application. If employed, this document will become part of your personnel file.
Personal Information
Social Security Number
First Name
Middle Name
Last Name
Preferred Name
Address Line 1
Address Line 2
City
State
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
BAKER ISLAND
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FED. STATES OF MICRONESIA
FLORIDA
GEORGIA
GUAM
HAWAII
HOWLAND ISLAND
IDAHO
ILLINOIS
INDIANA
IOWA
JARVIS ISLAND
JOHNSTON ATOLL
KANSAS
KENTUCKY
KINGMAN REEF
LOUISIANA
MAINE
MARSHALL ISLANDS
MARYLAND
MASSACHUSETTS
MICHIGAN
MIDWAY ISLANDS
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NAVASSA ISLAND
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OHIO
OKLAHOMA
OREGON
PALAU
PALMYRA ATOLL
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
US MINOR OUTLYING ISLANDS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WAKE ISLAND
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
Zip
E-mail Address
Home Telephone
Work Telephone
Mobile Telephone
1.
Are you legally authorized to work in the United States?
Please select
Yes
No
2.
Are you willing to work full-time?
Please select
Yes
No
If No, please list the days and hours you are willing to work:
3.
Have you previously applied for a position with our company?
Please select
Yes
No
If Yes, please provide the Month/Year
and Office
4.
Have you ever been convicted of a felony?
Please select
Yes
No
5.
Do you have any physical condition which could limit your ability to perform the job applied for or be aggravated by the job applied for? (If Yes, please use the space under Additional Information to explain.
Please select
Yes
No
6.
Salary range expected?
7.
If offered employment, when could you start?
8.
How did you hear about Cardiac Disease Specialists, P.C.?
Employment History
Current Employer:
Address:
Phone Number:
Position:
Date Hired:
Date Separated:
Reason for Leaving:
Supervisor:
Beginning Salary:
Ending Salary:
Other compensation or benefits:
May we contact your employer?
Please select
Yes
No
Previous Employer:
Address:
Phone Number:
Position:
Date Hired:
Date Separated:
Reason for Leaving:
Supervisor:
Beginning Salary:
Ending Salary:
Other compensation or benefits:
May we contact your employer?
Please select
Yes
No
Previous Employer:
Address:
Phone Number:
Position:
Date Hired:
Date Separated:
Reason for Leaving:
Supervisor:
Beginning Salary:
Ending Salary:
Other compensation or benefits:
May we contact your employer?
Please select
Yes
No
Educational Background
College, Trade School, or Special Training
Name of school:
Location:
Dates attended:
Degree/Certificate:
Major/Concentration:
Name of school:
Location:
Dates attended:
Degree/Certificate:
Major/Concentration:
Name of school:
Location:
Dates attended:
Degree/Certificate:
Major/Concentration:
High School
Last High School Attended:
Location:
Last Grade Completed :
Certificates and Licenses
Title:
License #:
Date Earned:
State Issued:
Title:
License #:
Date Earned:
State Issued:
Title:
License #:
Date Earned:
State Issued:
Professional References
Name:
Relationship:
Title:
Phone Number:
Name:
Relationship:
Title:
Phone Number:
Name:
Relationship:
Title:
Phone Number:
Additional Information
Upload your resume: (We only accept files in
pdf
or
doc
format)
I understand that employment with Cardiac Disease Specialists, P.C. is at will. I am aware that employment with Cardiac Disease Specialists, P.C. is contingent upon several factors, including satisfactory background and reference checks. All representations made by me on this application are true and correct, and I understand that any false statements or omissions may be cause for dismissal if hired.