Apply - Memphis Obstetrics & Gynecological Association, P.C

Position(s) Applied For:*

Preferred Office Location:*

Are you over the age of 18?*

Yes
No

Are you seeking:*

Full-time
Part-time

When could you start work?*

Name*

First Name Middle Initial Last Name

Other names used in prior employment?

Telephone Number*

Email Address*

Present Street Address*

Present Street Address City State ZIP Code

How long have you lived at this address?

If hired, can you furnish proof you are eligible to work in the U.S.?*

Yes
No

Are you vaccinated or have a medical or religious exemption from receiving a COVID-19 vaccine?*

Yes
No

If hired, you will be required to prove that you have received the COVID-19 vaccine or have a valid medical or religious reason to not be vaccinated.

Have you applied for any position with us or any of our practices before?*

Yes
No

If yes, when, what position and which location?

Have you ever been convicted of anything other than minor traffic violation?*

Yes
No

(Conviction of such a crime does not constitute an absolute bar to employment)

If yes, please explain:

Have you ever served in the armed forces?

Yes
No

Have you ever been employed by us or any of our practices before?*

Yes
No

If so, When and Where?

Do you have any relatives currently working for us or any of our practices?*

Yes
No

If yes, please list the name(s)

Education

High School

School Name Year Graduated # of Years Completed Course Of Study Diploma or Degree

College

School Name Year Graduated # of Years Completed Course Of Study Diploma or Degree

Other (specify)

School Name Year Graduated # of Years Completed Course Of Study Diploma or Degree

What skills or additional training do you have that are related to the job for which you are applying?

For Administrative Personnel:

With what software are you proficient?

Microsoft Office
Excel
Word
PowerPoint
Electronic Medical Record

If yes, what systems?

For Professional Personnel:

Licensed As:

State

Current License No.

State

Current License No.

Have any license privileges been suspended or revoked?

Yes
No

If so, why and where?

Employment Record

Starting with present or most recent, list all previous employers. Include self-employment, summer, part-time jobs and any period of unemployment. If you need more space, please continue on a separate sheet. Please indicate any change of name or assumed name used. Any gaps in information will cause this to be rejected as an incomplete application.

Name of Employer:

Job Title and Duties:

Address

Street Address City State ZIP Code

Dates of Employment:

Pay:

Supervisor:

Telephone:

Reason For Leaving:

Name of Employer:

Job Title and Duties:

Address

Street Address City State ZIP Code

Dates of Employment:

Pay:

Supervisor:

Telephone:

Reason For Leaving:

Name of Employer:

Job Title and Duties:

Address

Street Address City State ZIP Code

Dates of Employment:

Pay:

Supervisor:

Telephone:

Reason For Leaving:

If you are now employed, may we contact your employer?

Yes
No

If presently employed, why do you desire to change your position?

What are you salary requirements?

Personal References

Name of Three Persons, Not Relatives, Who May Be Contacted at The Present Time.

Name/Occupation

Email Address

Phone

Name/Occupation

Email Address

Phone

Name/Occupation

Email Address

Phone

Authorization

Please read each statement carefully before signing. I authorize investigation of all statements contained in this application (if I am considered for employment) and hereby authorize previous employers, personal references named, or any other person or persons to whom the company may refer, to give any and all information regarding my background if requested. In the event of my employment to a position at Memphis Obstetrics & Gynecological Association, PC, I will comply with all rules and regulations as set forth within the policies and procedures of the Company, or other communications the Company may distribute to its employees. If a job offer is made, I agree to complete a health evaluation which any include a physical examination by a physician selected by Memphis Obstetrics & Gynecological Association, PC (at the Company’s expense). Additionally, I authorize Memphis Obstetrics & Gynecological Association, PC, to supply my employment record in whole or in part to only those agencies having legal or proper interest. I further authorize Memphis Obstetrics & Gynecological Association, PC to use my photograph in connection with its advertising and public relations programs, in the event that I should become an employee. I hereby certify that I have read and do understand all of the above statements, that all statements made by me are true and accurate to the best of my knowledge, and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that any false statements or material omissions may be grounds for refusal to hire, or for immediate dismissal. I certify that I am at least 18 years of age and am legally authorized to work in the United States. Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Memphis Obstetrics & Gynecological Association, PC and myself for either employment or the providing of any benefit. I further understand that if I am employed by Memphis Obstetrics & Gynecological Association, PC, my unemployment will be for no definite term (at-will), and that either I or my employer will have the right to terminate the employment relationship at any time, with our without cause. I also understand that this status can only be altered by a written contract of employment which is specific to all material terms and is signed by both an officer of the employer and myself. I understand that as a condition of this application and any employment with Memphis Obstetrics & Gynecological Association, PC, I may be required to submit to testing for the presence of drugs and alcohol. I hereby consent to such testing. I further acknowledge that no promises regarding employment have been made to me, and that no promise or guarantee is binding upon the employer unless made in a written contract as described above.

Applicant's Signature*

Date*

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Education

Employment Record

Personal References

Authorization