Employment Application - Northside Medical Professionals

Northside Medical Professionals Employment Application

It is the policy of Northside Medical Professionals, P. C. to provide equal employment opportunities to all applicants and employees without regard to any legal protected status such as race, color, religion, gender, national origin, age, disability or veteran status.

Contact: Northside Medical Professionals, P.C., 1605 Nashville Hwy., Ste. 200, Columbia, Tn. 38401 • 931-540-4210

Title

First Name

Last Name

Email Address

Street

City

State

Zip Code

Years @ Address

Contact Phone

Alternate Phone Number

Social Security Number

Applicant's Background

Position Applying For

Have you applied here before?

No Yes

If yes, when?

Are you at least 18 years old?

No Yes

Are you willing to work any shift including nights and weekends?

No Yes

If not, please explain.

If offered a position, when could you begin?

Are you legally eligible for employment in the United States?

No Yes

Are you able to perform the essential functions of this position with reasonable accommodations?

No Yes

What reasonable accommodations, if any, would you require?

Have you ever been convicted of a crime?

No Yes

If yes, please describe.

The existence of a criminal record does not constitute an automatic bar to employment unless relevant to the type of employment.

Applicant's Education and Training

Upload CV

Please upload your CV in PDF format.

College Name

Street

City

State

Zip Code

Did you recieve a degree?

No Yes

If yes, what degree?

High School Name

Street

City

State

Zip Code

Last Grade Finished

Did you recieve your diploma

No Yes

Other training, awards, honors, or special achievements.

Applicant's Employment History

Employer Name

Street

City

State

Zip Code

Job Duties

Reason for Leaving

Employment Start Date

Employment End Date

Employer Name

Street

City

State

Zip Code

Job Duties

Reason for Leaving

Employment Start Date

Employment End Date

Employer Name

Street

City

State

Zip Code

Job Duties

Reason for Leaving

Employment Start Date

Employment End Date

References

List any people who would be willing to provide a reference for you.

First Name

Last Name

Street

City

State

Zip Code

First Name

Last Name

Street

City

State

Zip Code

First Name

Last Name

Street

City

State

Zip Code

Certification

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize Northside Medical Professionals, P.C. to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.

If I am called back for hire, I give permission for Northside Medical Professionals, P.C. to do a urine drug screen test and a TB skin test. I understand that if these tests come back positive it will be the basis for rejection of my hire.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.