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Application For Employment

NAME:  
    Last First Middle
ADDRESS:
  Number/Street City State Zip Code
SOCIAL SECURITY NUMBER: EMAIL ADDRESS:
TELEPHONE NUMBER WITH AREA CODE: Home Cell/Other
POSITION APPLIED FOR:
Salary Expected: $ Date Available: Days/Times Available:
How did you learn of Clinical Associates? (If referred by a current employee, please identify here)
Have you previously worked for Clinical Associates?
If yes, name at time of employment if other than current name
If yes, list dates, location, department, and titles
If previously employed, why did you leave?
Have you applied for employment with Clinical Associates, P.A. before? Date:
Are you legally eligible to work in the United State?
Name & Location of School Last Year Completed Did you Graduate Major Course Degree Received:
High School:
College:
Other:    

Prior Employment:

Employer Name &
Address		 Supervisor & Phone
No.		 Dates of
Employment		 Job Title(s) Pay
Rate		 Reason for Leaving
Have you had disciplinary problems with any previous employer?
If yes, please name the employer and describe the circumstances:
PLEASE LIST THREE INDIVIDUAL REFERENCES FROM PEOPLE WHO ARE FAMILIAR WITH YOUR WORK, SKILLS, ABILITY AND CHARACTER (PREVIOUS SUPERVISOR/MANAGERS PREFERRED):
Name Phone Address How long known? What capacity?
LIST ANY SPECIAL EXPERIENCES (VOLUNTEER, ETC.), QUALIFICATIONS OR SKILLS YOU HAVE THAT YOU BELIEVE WOULD HELP YOU DO THE JOB APPLIED FOR:
LIST ANY SPECIAL LICENSES OR CERTIFICATIONS YOU HAVE THAT YOU BELIEVE WOULD HELP YOU DO THE JOB APPLIED FOR: (List Licensing Authority, Number & Date of License for each)
IF YOU ARE APPLYING FOR A POSITION AS A MEDICAL ASSISTANT
You must be a Registered or Certified MA from a National Accrediting agency. Agency Name:
Date of Certification: Expiration Date on current Certificate:
Do you have a valid State Medical Assistant Certification License?  Number
Do you have a valid driver’s license? State Number
LIST ANY EXPERIENCE YOU HAVE IN OPERATING COMPUTERS OR OTHER BUSINESS EQUIPMENT THAT YOU BELIEVE WOULD BE USEFUL IN THE JOB APPLIED FOR:

UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.


Date  Signature of Applicant (name in above field will act as signature)






INFORMATION FOR APPLICANT

(Please Read Carefully Before Signing)

This application is valid for only ninety (90) days. If you have not been employed within ninety (90) days of your application, you must re-apply for a position.

By my signature below, I agree to the following:

  1. I consent to take any physical examinations, including but not limited to tests for alcohol or drugs, that may be requested by Clinical Associates: (1) following an offer of employment and prior to commencement of work; and (2) during the course of my employment, consistent with applicable law, including but not limited to the Americans With Disabilities Act. I further authorize any health care professional who performs such an examination or who has other information concerning my physical, mental or other medical status to release such information to Clinical Associates.
  2. I understand that any false statements or misleading omissions made by me in connection with my application, or in responding to requests for information, will be sufficient grounds for my rejection as a candidate for employment or for my immediate discharge.
  3. I understand that any employment I might be offered by Clinical Associates is at-will and of indefinite duration, and that either Clinical Associates or I can terminate that employment at any time with or without notice for any or no reason, and that no agreement to the contrary will be recognized by Clinical Associates unless made in writing and signed by the CEO of Clinical Associates. I understand that satisfactory completion of my provisional period will not change my status as an at-will employee.
  4. I understand that none of Clinical Associates’ practices or policies are to be construed as imposing any binding obligations on the Company, and that they are subject to change or deletion at any time.
  5. I hereby authorize Clinical Associates to obtain from schools, former employers, or other individuals or institutions it contacts, any information in their possession regarding my employment history or qualifications for the job for which I have applied.
  6. I understand and agree that Clinical Associates may engage an outside investigator to conduct an investigation of my conduct if I am accused of wrongdoing in my employment with Clinical Associates.

I have read this Employment Application and I understand its contents.

Date  Signature of Applicant (name in above field will act as signature)