Elkhart ClinicApplication for Employment Name * First Name Last Name Date * MM DD YYYY Present Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Are you 18 Years or Older: * Yes No Email Address * Do you presently have lawful, unexpired authorization to be employed by Elkhart Clinic in the United States: * Yes No Position Desired * Date you can start (mm-dd-yyyy) * Have you applied to Elkhart Clinic in the Past 12 Months? * Yes No Have you ever been employed by Elkhart Clinic? * Yes No If so, when? How did you hear about us? * Type of employment desired: * Full-Time Part-Time Temporary Have you ever been convicted of a crime that has not been expunged by a court, other than a minor traffic offense (this includes no contest or guilty pleas): * Yes No If yes, please explain (including dates and locations): (A criminal conviction will not necessarily bar you from employment.) Employment History * (From) MM DD YYYY * (To) MM DD YYYY Employer * Job Title * Summarize the nature of work performed or job responsibilities * Reason for Leaving * Hourly Rate / Salary Employment History (#2) (From) MM DD YYYY (To) MM DD YYYY Employer Job Title Summarize the nature of work performed and job responsibilities Reason for Leaving Hourly Rate / Salary Employment History (#3) (From) MM DD YYYY (To) MM DD YYYY Employer Job Title Summarize the nature of work performed and job responsibilities Reason for leaving Hourly Rate / Salary Skills / Qualifications Summarize any training, skills, licenses, and/or certifications that may qualify you as being able to perform job-related functions in the position for which you are applying: Educational Background High School Name & Location Years Completed Did you graduate Yes No Major Subject College Name & Location Years Completed Dd you graduate Yes No Major Subject Other I CERTIFY THAT ALL INFORMATION I HAVE PROVIDED TO ELKHART CLINIC IS TRUE AND ACCURATE, AND I UNDERSTAND THAT ANY FALSE INFORMATION, MISREPRESENTATION OR OMISSION MADE OR PROVIDED BY ME AT ANY TIME MAY RESULT IN NO FURTHER CONSIDERATION OF MY APPLICATION OR, IF I HAVE BEEN HIRED, IMMEDIATE DISCHARGE FROM ELKHART CLINIC'S SERVICE, WHENEVER IT IS DISCOVERED. I GIVE ELKHART CLINIC THE RIGHT TO CONTACT AND OBTAIN INFORMATION FROM ALL REFERENCES, EMPLOYERS, EDUCATIONAL INSTITUTIONS AND TO OTHERWISE VERIFY THE ACCURACY OF THE INFORMATION I HAVE PROVIDED TO IT. I HEREBY RELEASE FROM LIABILITY ELKHART CLINIC AND ITS REPRESENTATIVES FOR SEEKING, GATHERING AND USING SUCH INFORMATION AND ALL OTHER PERSONS, CORPORATIONS OR ORGANIZATIONS FOR FURNISHING SUCH INFORMATION. ELKHART CLINIC DOES NOT UNLAWFULLY DISCRIMINATE IN EMPLOYMENT AND NO QUESTION ON THIS APPLICATION IS USED FOR THE PURPOSE OF LIMITING OR EXCLUDING ANY APPLICANT FROM CONSIDERATION FOR EMPLOYMENT ON A BASIS PROHIBITED BY LOCAL, STATE OR FEDERAL LAW. IF I AM HIRED, I UNDERSTAND THAT I AM AN EMPLOYEE AT WILL AND AM FREE TO RESIGN AT ANY TIME, FOR ANY REASON, AND WITHOUT PRIOR NOTICE, AND ELKHART CLINIC RESERVES THE SAME RIGHT TO TERMINATE MY EMPLOYMENT AT ANY TIME, FOR ANY REASON, AND WITHOUT PRIOR NOTICE. THIS APPLICATION DOES NOT CONSTITUTE AN AGREEMENT OR CONTRACT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OR DEFINITE DURATION. I UNDERSTAND THAT NO REPRESENTATIVE OF ELKHART CLINIC, OTHER THAN AN AUTHORIZED OFFICER, HAS THE AUTHORITY TO MAKE ANY ASSURANCES TO THE CONTRARY CONCERNING THE TERMS, CONDITIONS OR DURATION OF MY EMPLOYMENT. I FURTHER UNDERSTAND THAT ANY SUCH ASSURANCES MUST BE IN WRITING AND SIGNED BY AN AUTHORIZED OFFICER IN ORDER TO BE VALID AND ENFORCEABLE. I ALSO UNDERSTAND THAT IF I AM HIRED, I WILL BE REQUIRED TO PROVIDE PROOF OF IDENTITY AND LEGAL WORK AUTHORIZATION. I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions. * I Agree Thank you!
