If yes, when?

* Answering yes to the above question does not automatically disqualify you from employment since the nature of the offense, date, and the job for which you are applying will be considered

If you are applying for a position with minimum age requirements, you may be required to submit proof of age.

Please list the name and phone number of at least 3 references who are not former employers or relatives

Please list your most recent or relevant education.

Do not include any labor organization, or memberships that reveal race, sex, age, veteran status, disability, or other protected status

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 offer may be contingent upon acceptable references.

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 and also authorize any person, school, current employer (except as previously noted), past employers and organizations named in this application 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 SUBSEQUENT EMLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT OR GUARANTEE EMPLOYMENT FOR ANY DFINITE PERIOD OF TIME. ONLY THE PRACTICE MANAGER OR OWNER HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT 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 MATY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.