Medical Careers | Slocum Dickson Medical Group

Step 1 of 4

PERSONAL INFORMATION
Name*
First Last
Social Security No. (last 4 digits)
Present Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Email
Previous Address
Street Address Address Line 2 City State ZIP Code
How were you referred to Slocum-Dickson Medical Group, P.L.L.C?*
Do you have any relatives working for this organization?*
- Yes
- No
If yes, Name*
If yes, Relationship*
If yes, Department*
Have you ever been employed by this organization?*
- Yes
- No
If yes, what position?*
If yes, what department?*
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Do you have a legal right to work in the United States?*
- Yes
- No
Are you 18 years of age or older?*
- Yes
- No
If not, state your age*

PROFESSIONAL LICENSES/CERTIFICATIONS:
License/Certification Type 1

State

Expiration Date
MM slash DD slash YYYY

Registration Number

License/Certification Type 2

State

Expiration Date
MM slash DD slash YYYY

Registration Number

License/Certification Type 3

State

Expiration Date
MM slash DD slash YYYY

Registration Number

PREVIOUS EXPERIENCE
Please list all names, address, and telephone number of previous employers, with most recent employer first. Periods of unemployment should be included.
Job Title

Employer Name

From
MM slash DD slash YYYY

To
MM slash DD slash YYYY

Immediate Supervisor
First Last
Duties:
Reason for Leaving

Job Title

Employer Name

From
MM slash DD slash YYYY

To
MM slash DD slash YYYY

Immediate Supervisor
First Last
Duties:
Reason for Leaving

Job Title

Employer Name

From
MM slash DD slash YYYY

To
MM slash DD slash YYYY

Immediate Supervisor
First Last
Duties:
Reason for Leaving

May we run an employment check from the employers listed above?

Yes

No
Has notice been given to present employer?

Yes

No
Are any of your academic or work history records listed in a previous name?

Yes

No
If yes, please explain.*

REFERENCES
Please list references (not relatives) to contact who are acquainted with your work history. Please provide at least ONE professional reference.
Name*
First Last
Title/Occupation*

Company/Address
Street Address Address Line 2 City State ZIP Code

Phone
Name*
First Last
Title/Occupation*

Company/Address
Street Address Address Line 2 City State ZIP Code

Phone
Name*
First Last
Title/Occupation*

Company/Address
Street Address Address Line 2 City State ZIP Code

Phone
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The undersigned authorizes the Group, at the time of my application for employment, or during the course of my employment, to obtain information from any source as to my education, experience, competence, or character, as it relates to the position for which I have applied or in which I may be employed. I agree not to assert any claims or causes of action of any kind against the Group, its agents, its employees, or any individual contacted by the Group as part of its investigation. I further release and forever discharge the Group, its agents, its employees, and the and the individuals, and companies contacted by the Group as part of its investigation from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever arising from the Group’s verification of the information contained in this Application.

I certify that the information in this Application is true, complete, and correct to the best of my knowledge and belief. I understand and acknowledge that any falsification or omission of information may cause my immediate dismissal or rejection of this Application. I also understand and acknowledge that should the Group extend an offer of employment, I will require to submit to a medical examination and pre-employment drug screen testing to determine my fitness for employment and that the offer of employment will be conditioned on the results of said medical examination. I also understand and acknowledge that during the course of my employment I may be required to submit to subsequent medical examinations and drug test screening that are job related and consistent with business necessity.

I further understand and acknowledge that in the event I am employed, such employment is at will. Neither I nor the Group have agreed on any specific period of employment nor any specific pay or benefits unless otherwise set forth in a separate agreement subscribed to in writing by the Group and myself.
Date*
MM slash DD slash YYYY

Signature*

Employment Application

Step 1 of 4

PERSONAL INFORMATION

EDUCATION

High School:

College:

College:

Technical, Business or Professional:

PROFESSIONAL LICENSES/CERTIFICATIONS:

PREVIOUS EXPERIENCE

REFERENCES