Employment Application Please enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Address Line 1Address Line 2CityColoradoAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *EmailConfirm EmailAre you at least 18 years of age or older? *YesNoWhat 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 / Ending rate of pay *FirstLastStart 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 / Ending rate of pay *FirstLastStart 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 QUESTIONSHave you ever been convicted of a criminal offense (felony or mistemeanor)? *YesNoNote: No applicant will be denied employment solely on the grounds of conviction for a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event and the surrounding circumstances and the relevance of the offense to the position applied for may, however, be considered.Do 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 ATTESTATIONApplicant Attestation *I have read and understand the below statement *By submitting this application 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 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. All candidates who receive an offer of employment will be required to undergo testing for commonly-abused controlled substances. Successful completion of drug screening is a requirement for employment at Family Physicians of Greeley, PLLP. All candidates who receive an offer of employment are subject to a background investigation for social security number verification and criminal history. I agree, if employed, to abide by all Family Physicians of Greeley, PLLP rules and regulations. I understand that such employment is for an indefinite period of time and that Family Physicians of Greeley, PLLP can change wages, benefits and conditions of employment at any time. Family Physicians of Greeley, PLLP is an equal opportunity employer. Qualified applicants will be considered for openings without regard to race, color, religion, sex, age, national origin, veteran status, or disability. Information on this application will not be used to discriminate against any applicant. 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