Prompt Med Urgent Care Centers

Prompt Med Urgent Care Centers CAREER OPPORTUNITY FORM
STEP 1 - APPLICATION FOR EMPLOYMENT
RETURN TO CAREERS PAGE

SECTION I.

Date:

Location Applied For:

Position Desired:

Name:

Email:

Phone:

Previous Address:

How Long?

Current Address:

How Long?

Social Security Number

Number of Children:

Ages:

SECTION II. BECAUSE OF FEDERAL LAW, ANSWERS TO QUESTIONS IN SECTION II ARE VOLUNTARY AND NOT REQUIRED FOR EMPLOYMENT.

Date of Birth:

Place of Birth:

Marital Status:

Weight:

Height:

Race:

Sex:

Spouse's Name:

Spouse's Occupation:

SECTION III.

Do you have any hour limitations for working?

If so, what?

Do you have any health problems?

Condition of health?

Whom should we notify in case of accident:

Their phone number:

Relationship:

Amount of overnight travel acceptable:

SECTION IV.

Have you had any past experience in the chiropractic, medical, dental or osteopathic fields?

If so, please describe:

SECTION V. PAST EMPLOYMENT - START WITH MOST RECENT EMPLOYMENT:

A. Past Employment:

How long?

Salary:

Phone:

Describe your job/responsibilities:

What did you enjoy most about the position?

What did you enjoy least?

B. Past Employment:

How long?

Salary:

Phone:

Describe your job/responsibilities:

What did you enjoy most about the position?

What did you enjoy least?

C. Past Employment:

How long?

Salary:

Phone:

Describe your job/responsibilities:

What did you enjoy most about the position?

What did you enjoy least?

SECTION VI. LIST REFERENCES

Name:

Address:

Phone:

Name:

Address:

Phone:

Name:

Address:

Phone:

Name:

Address:

Phone:

SECTION VII. EDUCATION/SKILLS

Highest level of education obtained:

LIST ANY DEGREES YOU HAVE OBTAINED:

CA:

BS:

BA:

RN:

LPN:

RT:

Other (Specify):

Other (Specifiy):

CHECK SKILLS YOU HAVE ACQUIRED (check all that apply):

Typing:

Accounting:

Shorthand:

Telephone Communictions:

Dictaphone

Physical Therapy:

Bookkeeping:

Other Special Skills (specify):

CAREER AIMS/PERSONALITY ASSESSMENT

Career Aims (What qualifications, abilities, and strong points will help you to succeed in this position?

SECTION VIII. LIST YOUR SIX BEST ASSETS.

Do you feel you are average?

Do you have self-confidence?

How do you see yourself:

How do you feel you would be suited for this position?

REQUIRED CHECKBOX! DO NOT CLICK THE SUBMIT BUTTON BELOW BEFORE CHECKING THIS BOX OR YOU MAY LOOSE ALL YOUR DATA!
By checking this box, I understand and agree with the terms and conditions of this online job application form: