Careers at FPG – Family Physicians of Greeley, PLLP

EMPLOYMENT APPLICATION

First name *

Last name *

Address *

City *

State *

Zip code *

Phone *

Are you at least 18 years of age? *

Position you are applying for *

Date available *

Salary desired *

Are you seeking full-time or part-time work? *

Full-time
Part-time
Either

Are you available to work Saturdays? *

Yes, usually
Yes, sometimes
No

Are you available to work evenings? *

Yes, usually
Yes, sometimes
No

EMPLOYMENT HISTORY

EMPLOYER #1: Current or most recent employer *

Start date *

End date *

Job title *

Ending rate of pay *

Employer address *

Supervisor *

Duties *

Reason for leaving *

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EDUCATION

High School

High school name *

High school location *

Did you graduate high school? *

College

College name

College location

College course of study

Did you graduate college?

Yes
No
Still enrolled

Other Education

School

Location

Course of study

Did you graduate?

Yes
No
Still enrolled

SKILLS

Professional credentials you hold, including license number and expiration date

List computer software with which you are proficient

Languages other than English in which you are fluent

REFERENCES

Please provide the name, employer and contact information of three persons not related to you with whom you have worked in the past five years.

Reference #1 *

Reference #2

Reference #3

APPLICANT ATTESTATION

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.

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. ------------------------------- X __________________________________________ Signature/Date *

I have read and understood the above *

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