In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, creed, religion, national origin, sex, marital status, status regarding public assistance, disability, sexual orientation, age, or any other protected group status. Complete the entire application. You may attach a resume, but you must still complete all questions or your application may be deemed incomplete and may not be considered. Please fill out each box (don't just indicate “See Resume”). Applications with missing or invalid information may not be considered for any position.
General Information Last Name * First Name * Middle Name Other names by which you are known Street Address * City * State * Zip * Email * Phone * Date of Birth * Social Security Number City & State of Birth Country of Birth Are you eligible to work in the United States? * Are you 18 years of age or older? * If NO, what is your current age? Have you ever been employed by Axis Medical Center? * If YES, when was your last date of employment? Reason for leaving: If required for position, do you have a valid driver's license? * If YES, State of issuance, license # and expiration date: How did you learn about this employment opportunity? Education High School Name of School City, State Did you graduate? If NO, # of years completed: If YES, date of graduation: Certificate Received: College Name of College College City, State Did you graduate from your program? If NO, what percent complete? If YES, graduation date: Degree/Certificate Received Field of Study Other School Name of other school Location Did you complete? In NO, percentage of completion: If YES, completion date: Topic of Study Other Credentials Please list any other credentials, licenses, professional affiliations, etc., which are relevant to the position(s) for which you are applying. Please list technical skills, clerical skills, trade skills, etc., relevant to this position. Employment History Most Recent Employment Organization Name Organization Address Job Title Years Employed Employment Type Primary Duties: Starting Salary Ending Salary Supervisor's Name, Title & Phone # Other Reference name, title & phone # May we contact this employer? Reason for leaving latest employer Next Most Recent Employer 2nd Organization Name 2nd Organization Address 2nd Job Title 2nd Job years employed 2nd Employment Type 2nd Primary Duties 2nd Starting Salary 2nd Ending Salary 2nd Supervisor's Name, Title & Phone # 2nd Other Reference name, title & phone # May we contact this 2nd employer? Reason for leaving 2nd employer Third Most Recent Employer 3rd Organization Name 3rd Organization Address 3rd Job Title 3rd Job years employed 3rd Employment Type 3rd Primary Duties 3rd Starting Salary 3rd Ending Salary 3rd Supervisor's Name, Title & Phone # 3rd Other Reference name, title & Phone # Reason for leaving 3rd employer
I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date. I authorize Axis Medical Center to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. I agree to submit to a physical exam, criminal and/or credit background investigation, and/or screening for illegal substances upon conditional offer of employment. I understand that this document is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract for continued guaranteed employment. I understand that staff employees of Axis Medical Center serve at-will, and the employment relationship may be terminated at any time by either party, for any or no reason, other than a reason prohibited by law. If employed, I understand that I will be required to furnish proof of eligibility to work in the United States. PLEASE READ CAREFULLY. UPON SUBMISSION, YOU ACKNOWLEDGE THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION.