Apply Online - Premier Surgical

Position(s) Applied For*

Office Location*

Date of Application*

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Alternate Phone

Email*

Are you legally eligible to work in the United States?*

Yes

No

(Proof of eligibility will be required upon offer of employment)

Are you over the age of 18 years?*

Yes

No

Can you with or without reasonable accommodation perform the essential functions of this job?*

Yes

No

(If you have any questions about the functions of the job, please ask the Interviewer before answering this question.)

Have you ever been excluded from the Medicare Program?*

Yes

No

Please explain.*

Were you referred for this position by a current Premier Surgical employee?*

Yes

No

Name of referring Premier Surgical employee:

Is anyone related to you employed by Premier Surgical?*

Yes

No

Please give their name and relationship to you.*

On what date would you be available to work?*

Attach Your Resume

Accepted file types: pdf, doc, docx, Max. file size: 2 MB.

Education

High School

Name and Location of School

Diploma / Degree / Certificate

Dates

College

Name and Location of School

Course of Study

Diploma / Degree / Certificate

Or Number of Credit Hours

Dates

Vocational

Name and Location of School

Course of Study

Diploma / Degree / Certificate

Or Number of Credit Hours

Dates

Other

Name and Location of School

Course of Study

Diploma / Degree / Certificate

Or Number of Credit Hours

Dates

Please list any academic honors, scholarships, offices held, etc.

(Do not list any which reflect your race, color, religion, gender, national origin, age, disabilities or veteran status.)

List any applicable state licenses.

Describe any certification, specialized training, apprenticeships, or skills.

Please list computer software training and/or experience.

Employment History

(Begin with current or most recent employer. Do not exclude any employment. Include any applicable temporary employment. Attach a document with additional information if necessary. Current supervisor will not be contacted without your permission.)

Company Name

Employment Dates

Name & Title of Supervisor

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Describe Your Duties

Reason for Leaving and Explanation

Company Name

Employment Dates

Name & Title of Supervisor

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Describe Your Duties

Reason for Leaving and Explanation

Company Name

Employment Dates

Name & Title of Supervisor

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Reason for Leaving and Explanation

Describe Your Duties

Attach a Document To List Additional Job Experience if Neccessary

Accepted file types: pdf, doc, docx, Max. file size: 2 MB.

Please provide any other information that you feel will help us in considering your application for employment.

References

(Please list three persons, who are not related to you, who can provide professional references.)

Name*

First Last

Phone*

Relationship/Occupation*

Years Known*

Name*

First Last

Phone*

Relationship/Occupation*

Years Known*

Name*

First Last

Phone*

Relationship/Occupation*

Years Known*

APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION

PLEASE READ CAREFULLY BEFORE SIGNING

I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by Premier Surgical Associates that such employment with Premier is at will, for no specified duration and may be terminated by either Premier or me at any time, with or without cause or notice.

I hereby authorize any and all schools, former employers, references, courts and any others who have Information about me to provide such information to Premier and/or any of its representatives, and I release all parties involved from any and all liability for any and all damage that may result from providing such information.

BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS.

Date*

Signature*

Name

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