Patient Centered Medical Care Inc. Application Form

Application Form

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Personal Information

First Name *

Last Name *

Social Security Number

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - General Information

Date Available?

Position Applied For?

Desired Salary

Social Security Number

How did you hear about PCMC Inc. (required)

Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)

Yes No

If yes, please explain.

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Can you provide documentation of a driver's license and auto insurance?

Yes No

Drivers License Expiration Date:

Effective Date

Expiration Date

Auto Insurace Experation Date:

Effective Date

Expiration Date

Section 2 - Employment Verification

Are you a U.S. citizen? (required)

Yes No

If you are not a U.S. citizen, please indicate VISA type and number.

Effective Date

Expiration Date

Are you authorized to work in the U.S.? (required)

Effective Date *

Expiration Date *

Are you 18 years old or older? (required)

Yes No

Have you ever applied/worked for PCMC Inc.?

Yes No

Effective Date

Expiration Date

If so, when, reason for leaving

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Do you have friends and relative working for PCMC Inc.

Yes No

If yes, name and relationship

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If hired would you have transportation to and from work?

Yes No

If hired are you willing to submit and pass a control substance test?

Yes No

Are you able to perform the essential functions of the job for which you are applying either with/without reasonable accommodations?

Yes No

If NO describe the functions that cannot be performed

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Do you speak, write or understand any foreign languages?

Yes No

If yes, Languages?

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Section 3 - Education

Name of High School:

Effective Date

Expiration Date

Address of High School:

Did you graduate?

Yes No

Type of Degree

Name of College

Address of College

Did you graduate?

Yes No

Type of Degree

Additional Education (vocational, undergraduate, etc.)

Yes No

If yes, please list the name of the school and years attended (From/To)

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Section 4 - Other Training: Certifications/Licenses

Please check the box for the position you are applying for (required)

Please check the box for the position you are applying for (required)

Do you have a certificate, licensed, registration or special training in the area in which you are applying? (required)

Yes No

If Yes, Please indicate below

If No, please indicate below

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Input your certificate, or license, or registration number along with expiration date.

Effective Date

Expiration Date

Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention?

Yes No

Section 5 - Current Employment

Are you currently Employed? (required)

Yes No

Current Employer:

Effective Date

Expiration Date

Address:

City:

State:

Zip Code:

Position/Title:

Describe Your Responsibilities:

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Hours Worked:

Starting Salary

Ending Salary

Reason for Leaving:

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Supervisor's name/ Title

Supervisor's phone number

May we contact your employer for a reference?

Yes No

Section 6 - Previous Employment

Last Employer:

Effective Date

Expiration Date

Address:

City:

State:

Zip Code:

Position/Title:

Describe Your Responsibilities:

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Hours Worked:

Starting Salary

Ending Salary?

Reason for Leaving:

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Supervisor's Name/Title:

Supervisor's Phone:

May we contact your previous employer for a reference?

Yes No

Section 7 - 2nd Previous Employment

Last Employer

Effective Date

Expiration Date

Address

City

State

Zip Code

(Numeric Answer Only)

Position/Title

Describe your Responsibilities

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Hours Worked

Starting Salary

Ending Salary

Reason for Leaving

Supervisor's name/title

Supervisor's phone number

May we contact your previous employer for a reference?

Yes No

Section 8 - Reference 1

Name:

Company:

Address

Phone:

Relationship

Section 9 - Reference 2

Name:

Company:

Address

Phone:

Relationship

Section 10 - Emergency Contact Information

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Phone 1:

Phone 2:

Relationship:

Section 11 - Military Service

Are you or have you worked for the Military Service? (required)

Yes No

If yes Branch / Dates

Effective Date

Expiration Date

Active or In Active Duty?

Rank at Discharge

Type of Discharge

If other than honorable, explain

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I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or any document used to secure this position can be grounds for refection of application or , if am employed by PCMC Inc., terms for my immediate termination from the company. I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, by either me or PCMC Inc. I permit the company to examaine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional expereinces with them, without giving me prior notice of such disclosure. In addition, I release PCMC Inc., my former employers and all other persons, corporations partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.

Signature