Medical Center

Stone Oak

in San Antonio

 

Online Employment Application

General Information

Position(s) Applied For:

E-Mail Address:

Date: 02/22/2012

 

Referral Source:

Advertisement Employee Relative Government Employment Agency
Walk-In Private Employment Agency Other:

Name of Source (If Applicable):

 

Applicant Name:

First: Middle: Last:

 

Address:

Street:

City:

State:

Zip:

 

Contact Information:

Telephone Number:

If necessary, best time to call you at home is:

May we call you at work? Yes No

 

Employment Information:

If under 18, can you furnish a work permit? Yes No 18 Years or Older

Have you ever applied at South Texas Spinal Clinic, P.A. in the past? Yes No

Have you ever been employed? Yes No

Are you eligible for employment in this country? Yes No
(Proof of US Citizenship or immigration status will be required upon employment.)

Type of employment desired:
Full-Time Part-Time Temporary Seasonal Educational

Available for work:

Are you on lay-off and subject to recall? Yes No

Will you relocate if job requires it? Yes No

Will you travel if job requires it? Yes No

Are you able to meet the attendance requirements of the position? Yes No

Will you work overtime? Yes No

Have you ever been bonded? Yes No

Have you ever been convicted of a felony in the last 7 years? Yes No
(Such conviction may be relevant if job related, but does not bar you from employment.)

Driver's License (if job-related):

State:

 

Employment History

List your last year of employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in comments section below:

Employer:

Telephone:

Address:

Job Title:

Immediate Supervisor & Title:

Reason for Leaving:

Dates Employed:
From: To:

Hourly Rate/Salary (Started):
Per:

Hourly Rate/Salary (Final):
Per:

Summarize the nature of the work performed
and job responsibilities:

May contact for reference:
Yes No Later

 

Employer:

Telephone:

Address:

Job Title:

Immediate Supervisor & Title:

Reason for Leaving:

dates Employed:
From: To:

Hourly Rate/Salary (Started):
Per:

Hourly Rate/Salary (Final):
Per:

Summarize the nature of the work performed
and job responsibilities:

May contact for reference:
Yes No Later

 

Employer:

Telephone:

Address:

Job Title:

Immediate Supervisor & Title:

Reason for Leaving:

Dates Employed:
From: To:

Hourly Rate/Salary (Started):
Per:

Hourly Rate/Salary (Final):
Per:

Summarize the nature of the work performed
and job responsibilities:

May contact for reference:
Yes No Later

 

Comments: (including explanation of any gaps in employment)

 

Skills & Qualifications: (Summarize special skills and qualifications acquired from employment or other experience that may qualify you to work with our company.)

 

Educational Background (if job-related)

A. List last three (3) schools attended, starting with recent one. B. List number of years completed. C. Indicate degree or diploma earned, if any. D. Grade Point Average or Class Rank. E. Major and minor field of study (if applicable).

 

A. School 1
B. Number of
Years Completed 		C. Degree or Diploma D. GPA /
Class Rank 		E. Major / Minor

 

A. School 2
B. Number of
Years Completed 		C. Degree or Diploma D. GPA /
Class Rank 		E. Major / Minor

 

A. School 3
B. Number of
Years Completed 		C. Degree or Diploma D. GPA /
Class Rank 		E. Major / Minor

 

List any foreign language(s) you know and check the boxes that describe you skill level.

Language
Speak Some Speak Fluently Read Write
Speak Some Speak Fluently Read Write
Speak Some Speak Fluently Read Write
Speak Some Speak Fluently Read Write

 

References: List name and telephone number of three-business/work references that are not related to you and are not previous supervisor. If not applicable, list three school or personal references that are not related to you.

Name Telephone Years Known

 

List professional, trade, business, or civic associations and any offices held. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status.)

Organization Offices Held

 

List special accomplishments, publications, awards. (Exclude information which would reveal sex, race, religion, national origin, age, color disability or other protected status.)

 

List any additional information you would like us to consider.

 

You may also upload your resume as a .doc, .docx, or .pdf file.

Resume:

 

It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from employe's service if I have been employed.

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 limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law.

This application is current for only 60 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 understand that no representative of the Employer has the authority to make any assurances to the contrary.

Enter your name in the signature box and click "Submit Application" to agree to the terms above. You will recieve a confirmation e-mail and copy of this application at the e-mail address you provided.

Signature:

South Texas Spinal Clinic, P.A. is an equal opportunity employer.