Application for Employment

Please fill out the application form below and we will get back to you shortly.

APPLICATION FOR EMPLOYMENT

An Equal Opportunity Employer - Our practice does not discriminate on the basis of race, religion, national origin, color, sex, age, veteran status, disability, or any other status protected by applicable law or regulation. It is our intent that all qualified applicants are given equal opportunity and that selection decisions be based on job-related factors.

Date
Name
FirstLast
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Phone
Email
Position applied for:
Employment you are seeking:
- Full-time
- Part-time
Preferred location:
- North Bay
- Temple Terrace
- Pebble Creek
Specify days and hours if part-time:
Where you previously employed by this organization?
- Yes
- No
If yes, when?
List any friends or relatives working here, other than spouse:
If your application is considered favorably, on what date will you be available for work?
Are there any other work experiences, skills, or qualifications that you feel would especially qualify you for employment here?
Please add any additional comments you think are important for us to consider.
If hired, can you furnish proof you are eligible to work in the United States?
- Yes
- No
Have you ever been convicted of a felony?
- Yes
- No
A yes answer does not automatically disqualify you from employment since the nature of the offense, date, and the job for which you are applying for will be considered.
If 'yes', please explain:
Have you previously applied here?
- Yes
- No
If 'yes', when?
Have you worked for any entity under a different name?
- Yes
- No
If 'yes', give name:
For jobs with minimum age requirements:
If you are applying for a position with minimum age requirements, you may be required to submit proof of age.
Are you 18 year of age or older?
- Yes
- No
For driving positions only: Do you have a valid driver’s license?
- Yes
- No
Driver’s license number:
Type/Class of license:
Has your driver’s license been revoked or suspended in the last 3 years?
- Yes
- No
Personal References
(not former employers or relatives)
1) Name and Occupation:
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Phone
2) Name and Occupation:
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Phone
3) Name and Occupation:
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Phone
Education Record – Non-veterinarians Only
High School
Years Completed
Degree Awarded
Grade Average
Honors
College or University
Degree Awarded
Degree Awarded
Grade Average
Honors
Business, Trade, Correspondence, or Night School
Years Completed
Degree Awarded
Grade Average
Honors
Other Education
Years Completed
Degree Awarded
Grade Average
Honors
Do you type?
- Yes
- No
If 'yes', WPM?
(words per minute)
List office machines, computers, and software you are qualified to operate
List any special honors, recognitions, awards
Education Record – Veterinarians Only
High School
Years Completed
Degree Awarded
Grade Average
Honors
College or University (Pre-veterinary)
Years Completed
Degree Awarded
Grade Average
Honors
College (Veterinary Curriculum)
Years Completed
Degree Awarded
Grade Average
Honors
Postgraduate training (including internships, dates, and degrees awarded, if any)
Are you board certified?
- Yes
- No
Board Eligible?
- Yes
- No
Which specialty board?
List continuing education courses completed in the past 18 months
List the states in which you are licensed to practice along with license numbers
List any special honors, recognitions, and awards
Relevant Special Interests/ Organizations
(Do not include any labor organization or memberships that reveal race, sex, age, veteran status, disability, or other protected status)
Name or Description of Organization
Active Participation Date (From - To)
Offices Held
Name or Description of Organization
Active Participation Date (From - To)
Offices Held
Name or Description of Organization
Active Participation Date (From - To)
Offices Held
Work History
(Beginning with the most recent, list all past employers, including any pertinent military experience. If self-employed, provide the business name and business references. A job may be contingent upon acceptable references.)
Name of Company
Business Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Phone
Type of Business
Immediate Supervisor
FirstLast
Date Employed from
Date Employed to
Exact Job Title
Earnings at Hire
Earnings at Termination
Reason for Termination
Description of Duties
Name of Company
Business Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Phone
Type of Business
Immediate Supervisor
FirstLast
Date Employed from
Date Employed to
Exact Job Title
Earnings at Hire
Earnings at Termination
Reason for Termination
Description of Duties
Name of Company
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Phone
Type of Business
Immediate Supervisor
FirstLast
Date Employed from
Date Employed to
Exact Job Title
Earnings at Hire
Earnings at Termination
Reason for Termination
Description of Duties
Name of Company
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Phone
Type of Business
Immediate Supervisor
FirstLast
Date Employed from
Date Employed to
Exact Job Title
Earnings at hiring
Earnings at Termination
Reason for Termination
Description of Duties
Certification
I certify that all information I have provided in this application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal characteristics, and mode of living. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation. I authorize the investigation of any or all statements contained in this application. I also authorize whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand I may be required to successfully pass an alcohol/drug screening examination: I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required and if permitted by law. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUCSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT OR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRACTICE MANAGER OR OWNER HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY SUCH PERSON AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE. I have read, understand, and by my submission of online application, consent to these statements.
Name*
Date*