Employment Application Form

Applicant Information

Last Name:

First Name:

Middle Initial:

Date

Address:

Apartment/Unit #:

City:

State:

ZIP Code:

Phone:

Email:

Date Available:

Desired Salary:

Position Applied for:

Can you preform the essential functions of the job with or without accommodations?

Yes No

Are you a citizen of the United States?

Yes No

If no, are you authorized to work in the U.S.?

Yes No

Have you ever worked for this company?

Yes No

If yes, when?

Do you have any friends or relatives that work for Cleaver Derm?

Yes No

If yes, who?

Education

High School:

Address:

From:

To:

Did you graduate?

Yes No

Diploma:

College:

Address:

From:

To:

Did you graduate?

Yes No

Degree:

Other:

Address:

From:

To:

Did you graduate?

Yes No

Degree:

References

Please list three references. (not related to you)

Add another reference

Previous Employment

Are you presently employed?

Yes No

May we contact your employee?

Yes No

Add another employment history

Disclaimer and Signature

Cleaver Dermatology is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.

By signing, I hereby certify that the above information, to the best of my knowledge, is correct. I understand that falsification of this information may prevent me from being hired or lead to my dismissal, if hired. I hereby authorize Cleaver Dermatology to make such investigations and inquiries as to my character, employment record and conviction record and/or matters deemed necessary in arriving at an employment decision. I understand that my employment can be terminated with or without cause, at any time, at the discretion of the employer or myself.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

Your information will be encrypted.