Employment Application Form

Name

First

Last

Email *

Date

Position Desired

Minimum Salary

How did you learn about us?

Ever applied here before

Telephone Number

Alternate number

Employment Eligibility

Are you a citizen of the U.S.?

If not, do you have legal right to work in the U.S.?

Are you 16 years of age or older?

If not, please specify age

Do you speak or read any languages fluently besides English?

If yes, which one(s)

Have you ever been convicted of a felony crime?

Are there any criminal charges pending against you?

Background testing may be employment requirement. I understand that if I am offered a position, a background test may be required.

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Drug-Free Screening is an employment requirement. I understand that if I am offered a position, drug screening will be required prior to my employment.

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Education

Name of High School

City/State

Degree/Major

Name of College / University

City/State

Degree/Major

Name of Graduate School

City/State

Degree/Major

Name of Trade School

City/State

Degree/Major

Employment History

Employment Dates

Employers Name & Address

Position / Job Duties

Reason for leaving

Wage/salary

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Employment History

Employment Dates

Employers Name & Address

Position / Job Duties

Reason for leaving

Wage/salary

Is any information relative to change in name, use of an assumed name, maiden name, or nickname necessary to check your work record or background information? *

If yes, please provide other names

Do you authorize us to contact your previous and present employer for reference prior to employment with this business? *

Authorized signature

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Date

Is there anything else you would like us to know about you?

Applicant’s Affidavit:

I certify that the information contained in this application is correct to the best of my knowledge. I authorize investigation of all matters contained in this application and agree that any misleading or false statements would be cause for rejection of this application or would be sufficient cause for dismissal after employment begins.

I understand that employment is contingent upon the receipt of negative drug screening results, background check, and satisfactory work references by Harvey Memorial Animal Hospital. I further understand that my continued employment will be based on my satisfactory performance and the satisfactory completion of the Benefits Waiting period of employment.

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Date

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Called for interview

Interview scheduled

Arrived

Interviewed By

Date

Full-time or Part-time

Hours

Scheduling restraints

Remarks

Employment Application Form

Applicant’s Affidavit:

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