Employment Application

Our company Highlands Dermatology, P.A. fully subscribes to the principles of Equal Employment Opportunity. It is our policy to provide employment, compensation, and other benefits related to employment based on qualifications, without regard to race, color, religion, national origin, age, sex, veteran status, genetic information, disability, or any other basis prohibited by federal, state or local law. In accordance with requirements of the Americans with Disabilities Act and applicable federal, state and/or local laws, it is our policy to provide reasonable accommodation upon request during the application process to applicants in order that they may be given a full and fair opportunity to be considered for employment. As an Equal Opportunity Employer, we intend to comply fully with applicable federal, state and/or local employment laws and the information requested on this application will only be used for purposes consistent with those laws. To the extent required by applicable law, The Company maintains a smoke- free workplace.

If the box is checked the following exemption applies:

COMPANY NAME: Highlands Dermatology, P.A.

POSITION APPLIED FOR:

DATE:

PERSONAL DATA

Salary expectations:

Name:

Street Address:

City:

State:

Zip Code:

Telephone:

If you are under 18 years of age, please specify your age:

(This information will be used only for child labor law purposes).

Are there any days, shifts or hours you will not work?

Yes No

If yes, please explain:

Are you available for out of town work?

Yes No

Will you work overtime, if required?

Yes No

*Note: It is not necessary for you to identify unavailability for work because of religious observance or practice or any other protected classification. Subsequent to any job offer, we will consider whether a reasonable accommodation can be made

How did you learn of our Company?

Have you ever applied or worked at our Company before?

Yes No

If yes, provide dates:

Are you legally authorized to work in the United States?

Yes No

Will you now or in the future require sponsorship for employment visa status (e.g.,H-1B visa status)?

Yes No

Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification “Form I-9” be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.

DRIVING RECORD

(Answer only if driving is a requirement of the job for which you are applying).

Do you have a valid driver’s license?

Yes No

Please complete for all full-time or part-time employment beginning with most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis. All applicants should start with their most recent job, include military assignments and voluntary employment and provide ten (10) years of history. (A separate sheet may be attached.) You must explain any gaps in your employment history.

Add another employment

Have you ever been discharged or asked to resign from employment?

Yes No

If yes, explain:

Did you receive any discipline in your last 12 months of active employment with your previous employer?

Yes No

If yes, explain:

Were you given a performance evaluation within the last 12 months of active employment?

Yes No

If yes, what was the range of scores used and what was your score?

Have you signed any non-competition or non-solicitation agreement or any other kind of agreement with any other employer that might restrict you from working for the Company (you will be required to furnish a copy of the agreement if you are being considered for hire)?

Yes No

If yes, please explain:

Professional References

(Please list three individuals unrelated to you with whom you have worked who know your qualifications for this position.)

Name

Address

Phone

Relationship

Name

Address

Phone

Relationship

Name

Address

Phone

Relationship

Military

(Complete only if you served in the military.)

Branch of Service:

Number of Years /Months of Service:

Rank at Discharge:

Date of Discharge:

Describe any military skills, training or experience you believe are relevant to the job you applied for:

Lie Detector Tests

Massachusetts Applicants Note: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability

Maryland Applicants Note: An employer may not require or demand, as a condition or prospective employment or continued employment, an individual submit to or take a lie detector or similar test. An employer who violates this law is guilty of a misdemeanor and subject to a fine not exceeding $100. I have read and acknowledge this notice:

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.

Applicant's Signature:

Applicant's Acknowledgement

I certify that the answers given herein and during the entire application process (including but not limited to information provided in resumes, attachments to this application, interviews or otherwise (if applicable)) are true and complete to the best of my knowledge.

I understand that any misrepresentations, omissions of facts or incomplete answers during the application process may disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts during the application process may be cause for my dismissal at any time without prior notice.

I consent to and authorize the Company to contact my former employers, references, and any and all other persons and organizations for information bearing upon my qualifications for employment.

I further authorize the listed employers, schools and personal references to give the Company (without further notice to me) any and all information about my previous employment and education, along with any other pertinent information they may have and hereby waive any actions which I may have against either party(ies) for providing a good faith reference.

I EXPRESSLY AGREE AND UNDERSTAND THAT, IF EMPLOYED, MY EMPLOYMENT IS NOT FOR A SPECIFIC TERM, IS BASED ON MUTUAL CONSENT AND MAY BE TERMINATED BY ME OR THE COMPANY WITH OR WITHOUT NOTICE OR CAUSE AT ANY TIME. I FURTHER UNDERSTAND THAT NO ORAL PROMISE, EMPLOYER POLICY, CUSTOM, BUSINESS PRACTICE OR OTHER PROCEDURE (INCLUDING PERSONNEL HANDBOOK OR ANY PERSONNEL MANUALS) CONSTITUTE AN EMPLOYMENT CONTRACT OR MODIFICATION OF THE AT-WILL EMPLOYMENT RELATIONSHIP BETWEEN ME AND THE COMPANY. I ALSO UNDERSTAND THAT MY AT-WILL EMPLOYMENT STATUS WITH THE COMPANY MAY ONLY BE ALTERED IN AN INDIVIDUAL CASE OR GENERALLY IN A WRITING SIGNED BY THE OWNER, PRESIDENT OR CEO OF THE COMPANY.

I understand I may be required to qualify for employment based on additional employment criteria. For example, I may be required to take job-related tests; take a driver’s examination or take a preemployment drug test. If I am offered employment or start work before any required test is completed, I understand that my employment is contingent on a satisfactory result on all required tests. I authorize the release of any drug/alcohol test to any state or federal authority requesting such information and in response to a valid subpoena or other legal document. I agree to sign any additional forms necessary for drug tests to be conducted.

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:

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