Date: 8/23/2014

Application Form

Patient Centered Medical Care Inc.

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 * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - General Information

Number Question Effective Date Expiration Date
1. Date Available?  
     
2. Position Applied For?  
 
 
 
 
 
3. Desired Salary  
     
4. Social Security Number  
     
5. How did you hear about PCMC Inc. (required)  
     
6. Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)  
     
7. If yes, please explain.  
 
8. Can you provide documentation of a driver's license and auto insurance?  
     
9. Drivers License Expiration Date:  
 
10. Auto Insurace Experation Date:  
 

Section 2 - Employment Verification

Number Question Effective Date Expiration Date
1. Are you a U.S. citizen? (required)  
     
2. If you are not a U.S. citizen, please indicate VISA type and number.  
 
3. Are you authorized to work in the U.S.? (required)  
 
 
 
 
4. Are you 18 years old or older? (required)  
     
5. Have you ever applied/worked for PCMC Inc.?  
 
6. If so, when, reason for leaving  
 
7. Do you have friends and relative working for PCMC Inc.  
     
8. If yes, name and relationship  
 
9. If hired would you have transportation to and from work?  
     
10. If hired are you willing to submit and pass a control substance test?  
     
11. Are you able to perform the essential functions of the job for which you are applying either with/without reasonable accommodations?  
     
12. If NO describe the functions that cannot be performed  
 
13. Do you speak, write or understand any foreign languages?  
     
14. If yes, Languages?  
 

Section 3 - Education

Number Question Effective Date Expiration Date
1. Name of High School:  
 
2. Address of High School:  
     
3. Did you graduate?  
     
4. Type of Degree  
 
 
 
 
 
5. Name of College  
     
6. Address of College  
     
7. Did you graduate?  
     
8. Type of Degree  
 
 
 
 
 
9. Additional Education (vocational, undergraduate, etc.)  
     
10. If yes, please list the name of the school and years attended (From/To)  
 

Section 4 - Other Training: Certifications/Licenses

Number Question Effective Date Expiration Date
1. Do you have a certificate, licensed, registration or special training in the area in which you are applying? (required)  
     
2. If Yes, Please indicate below  
 
 
 
 
 
3. If No, please indicate below  
 
4. Input your certificate, or license, or registration number along with expiration date.  
 
5. Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention?  
     

Section 5 - Current Employment

Number Question Effective Date Expiration Date
1 Are you currently Employed? (required)  
     
2. Current Employer:  
 
3. Address:  
     
4. City:  
     
5. State:  
     
6. Zip Code:  
     
7. Position/Title:  
     
8. Describe Your Responsibilities:  
 
9. Hours Worked:  
 
 
 
 
 
10. Starting Salary  
     
11. Ending Salary  
     
12. Reason for Leaving:  
 
13. Supervisor's name/ Title  
     
14. Supervisor's phone number  
     
15. May we contact your employer for a reference?  
     

Section 6 - Previous Employment

Number Question Effective Date Expiration Date
1. Last Employer:  
 
2. Address:  
     
3. City:  
     
4. State:  
     
5. Zip Code:  
     
6. Position/Title:  
     
7. Describe Your Responsibilities:  
 
8. Hours Worked:  
 
 
 
 
 
9. Starting Salary  
     
11. Ending Salary?  
     
11. Reason for Leaving:  
 
12. Supervisor's Name/Title:  
     
13. Supervisor's Phone:  
     
14. May we contact your previous employer for a reference?  
     

Section 7 - 2nd Previous Employment

Number Question Effective Date Expiration Date
1. Last Employer  
 
2. Address  
     
3. City  
     
4. State  
     
5. Zip Code  
  (Numeric Answer Only)    
6. Position/Title  
     
7. Describe your Responsibilities  
 
8. Hours Worked  
 
 
 
 
 
9. Starting Salary  
     
10. Ending Salary  
     
11. Reason for Leaving  
     
12. Supervisor's name/title  
     
13. Supervisor's phone number  
     
14. May we contact your previous employer for a reference?  
     

Section 8 - Reference 1

Number Question Effective Date Expiration Date
1. Name:  
     
2. Company:  
     
3. Address  
     
4. Phone:  
     
5. Relationship  
     

Section 9 - Reference 2

Number Question Effective Date Expiration Date
1. Name:  
     
2. Company:  
     
3. Address  
     
4. Phone:  
     
5. Relationship  
     

Section 10 - Emergency Contact Information

Number Question Effective Date Expiration Date
1. First Name:  
     
2. Last Name:  
     
3. Address:  
     
4. City:  
     
5. State:  
     
6. Zip Code:  
     
7. Phone 1:  
     
8. Phone 2:  
     
9. Relationship:  
     

Section 11 - Military Service

Number Question Effective Date Expiration Date
1. Are you or have you worked for the Military Service? (required)  
     
2. If yes Branch / Dates  
 
3. Active or In Active Duty?  
 
 
4. Rank at Discharge  
     
5. Type of Discharge  
     
6. If other than honorable, explain  
 



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 otehr 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.