Employment Application : Surgery Center South

We consider all applicants solely on the basis of qualifications for the position for which application is made, without regard to race, color, religion, sex, national origin, age, veteran status, disability or any other legally protected status.

Application is considered active for 30 days from date of receipt.

Note: All questions must be completed. It is not acceptable to answer "See Resume".

1 Getting Started

2 Personal Information

3 Education

4 Employment History

5 General Information

6 References

7 Legal

Date*
MM
DD
YYYY
Position(s) Applied For:*
Use a comma to separate items.

High School
School Name*
City, State*
Years Completed/Degree Received*
College/University
School Name*
City, State*
Years Completed/Degree Received*
Did you graduate?*
- Yes
- No
Major Field of Study*
Graduate/Professional
School Name*
City, State*
Years Completed/Degree Received*
Did you graduate?*
- Yes
- No
Major Field of Study*
Summarize other information you believe pertinent to your application.
(include computer skills, software utilized, typing speed, vocational or business schools, paralegal certification, etc.)

Have you ever been convicted on a felony other than minor traffic violations?*
(a conviction is not an absolute bar to employment but will only be considered in relation to the specific job requirements)
- Yes
- No
Please explain.
Are you under any obligation to a current or former employer which may restrict your ability to accept employment?*
- Yes
- No
Please explain.
Have you served in the Armed Forces?*
- Yes
- No
Which branch?*
Enlistment Date*
MM
DD
YYYY
Discharge Date*
MM
DD
YYYY
Rank at discharge.*
Duties/Special Training*
Emergency Contact Information
Emergency Contact Name*
First Last
Emergency Contact Phone*
Emergency Contact Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship*

Please provide up to three references. Do not include relatives.
Reference #1 Name*
First Last
Reference #1 Phone*
Reference #1 Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of years known.*
Type of reference.*
- Personal
- Work-related
Add a second reference.
- Add a second reference.
Reference #2 Name*
First Last
Reference #2 Phone*
Reference #2 Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of years known.*
Type of reference.*
- Personal
- Work-related
Add a third reference.
- Add a third reference.
Reference #3 Name*
First Last
Reference #3 Phone*
Reference #3 Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of years known.*
Type of reference.*
- Personal
- Work-related

List professional, trade, business, or civic activities and offices held.
(You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, or disability or other protected status.)
Is there any additional information that you feel will help us determine the type of position you are able to undertake?
I hereby certify that all questions in this application have been answered completely and correctly. Should the employer at any time discover that any of the statements made by me on this application are false or incomplete as to any material information requested, such falsification will be grounds for immediate discharge. I agree that I will be bound by and will obey all rules and regulations of the company which may be issued from time to time, including all safety rules. I give the employer the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the employer and its representatives for seeking such information, and all other persons, corporations or organizations for furnishing such information.

The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limited or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 30 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I further acknowledge that no representative of the Center has any authority to alter or vary any of the terms of any of the policies or to bind the company to any fixed term of employment except as specifically authorized by the Operating Board Chairman or designee, and that any such agreement, to be enforceable, must be in writing and signed by the Operating Board Chairman, or designee.

I understand that it is policy not to refuse to hire a qualified individual with a disability because of this person’s need for accommodation that would be required by the ADA.
I hereby certify that I have read and agree to the above statement.
- I hereby certify that I have read and agree to the above statement.

Employment Application

High School

College/University

Graduate/Professional

Past Employment 1

Past Employment 2

Past Employment 3

Emergency Contact Information