Employment Application Please enable JavaScript in your browser to complete this form.Name *Address *Address Line 1Address Line 2CityColoradoAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *EmailConfirm EmailWhat position are you applying for? *Date Available *Desired Salary *Are you seeking full-time or part-time work? *Full-timePart-timeEitherAre you available to work Saturdays? *Yes, usuallyYes, sometimesNoAre you available to work evenings? *Yes, usuallyYes, sometimesNoEMPLOYMENT HISTORYEMPLOYER #1 - Current or most recent employer *Employer Address *Address Line 1CityColoradoAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeJob Title *Start Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SupervisorDuties *Reason for leaving *ADD ANOTHER EMPLOYERADD ANOTHER EMPLOYEREMPLOYER #2 *Employer Address *Address Line 1CityColoradoAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeJob Title *Start Date *End Date *Supervisor Duties *Reason for leaving *EDUCATIONHigh School High School Name *High School location *Did you graduate? YesNoGEDCOLLEGECollege NameCollege locationCourse of StudyDid you graduate?YesNoStill enrolledOther EducationSchoolLocationCourse of Study Did you graduate?YesNoStill enrolledSKILLSProfessional credentials you hold, including licesne number and expiration dateList all computer software with which you are proficient.Languages other than English in which you are fluentOTHER EMPLOYMENT QUESTIONSDo you have a VALID drivers license? *YesNoREFERENCESPlease provide the name, employer and contact information of three persons not related to you with whom you have worked for or with in the past 5 years.Reference #1 *Reference #2 *Reference #3 *APPLICANT'S CERTIFICATIONPlease read and check all boxes *I verify that all the information which I have provided on this application and in related materials is true, correct and complete. I understand that any false, misleading, incomplete or omitted information will result in rejection of my application, withdrawal of a job offer, or dismissal from employment, whenever discovered. I authorize such information to be used for any decisions relating to my hiring and continued employment. I release any and all persons or companies from any liability or damages for obtaining or releasing information or verifying statements provided by me.I understand that with an offer of employment, I will be required to undergo testing for commonly abused controlled substances. I also consent to a Social Security number verification and a criminal background screen and will provide requested information required to perform and complete these requirements. Failure to successfully complete these screenings may result in the withdrawal of the employment offer.I understand that if I am hired by Family Physicians of Greeley, PLLP, I must complete a Federal I-9 form and provide verifying documentation of my legal right to reside and work in the United States prior to beginning employment.I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT, DOES NOT CREATE AN EXPRESS OR IMPLLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.All offices of Family Physicians of Greeley are non-smoking environments.Electronic Signature *Please type your legal name as your E-Signature for this Application of EmploymentUPLOAD DOCUMENTSUpload documents such as a resume, cover letter or reference lettersFile Upload #1File Upload #2File Upload #3File Upload #4Submit Application