Employment Form

Personal
Name*
First Middle Last
Current Address*
Street Address City State ZIP Code
Phone*
Email*
Position Applied For:*
Rate of pay expected:*
- per hour
- per year
Would you work*
- Full-time
- Part-time
Specify days and hours if part-time:
Were you previously employed by us?*
- Yes
- No
If yes, when?
List any friends or family working here:
If your application is considered favorable, on what date will you be available for work?

Work History
Begin with the most recent, list all pat employers, including any pertinent military experience.
Name of Business*
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Type of Business*
Immediate Supervisor*
Dates of Employment*
From
To
Exact Job Title*
Earnings at Hire*
Earnings at End of Employment*
Why did you leave this company?*
Description of Duties*
Name of Business
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Type of Business
Immediate Supervisor
Dates of Employment
From
To
Exact Job Title
Earnings at Hire
Earnings at End of Employment
Why did you leave this company?
Description of Duties
Name of Business
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Type of Business
Immediate Supervisor
Dates of Employment
From
To
Exact Job Title
Earnings at Hire
Earnings at End of Employment
Why did you leave this company?
Description of Duties

Work References
Name and Occupation*
Phone
Address
Street Address City State ZIP Code
Name and Occupation*
Phone
Address
Street Address City State ZIP Code
Name and Occupation*
Phone
Address
Street Address City State ZIP Code

Personal References
Not former employers or relatives.
Name and Occupation*
Phone
Address
Street Address City State ZIP Code
Name and Occupation*
Phone
Address
Street Address City State ZIP Code
Name and Occupation*
Phone
Address
Street Address City State ZIP Code

Affidavit
l certify that all information l have provided in this application is true and complete. l understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character. reputation. personal characteristics and mode of living obtained from neighbors. friends. former employers, schools, and others. I understand I have the right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation. I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employer (except as previously noted) past employers, and organizations named in this application to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAYE BEEN HIRED AT TH£ WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE. I have read, understand, and by my signature: consent to these statements.
Signature*
Date*

Step 1 of 7

Personal

Work History

Work References

Personal References

Education Record - Nonveterinarians Only

Education Record - Veterinarians Only

Affidavit

AFFORDABLE ORTHOPEDIC EXCELLENCE