Larned Veterinary Clinic

LARNED VETERINARY CLINIC

APPLICATION FOR EMPLOYMENT

DATE OF APPLICATION:
NAME:
LAST / FIRST / MIDDLE / NICKNAME
ADDRESS:
STREET
CITY / STATE / ZIP
home ( ) / work ( )
TELEPHONE NUMBERS
EMAIL ADDRESS:
SOCIAL SECURITY NUMBER (optional):
POSITION APPLYING FOR:
HOW DID YOU HEAR ABOUT THE POSITION?
(if referred by anyone in our employ, state name)
DATE AVAILABLE TO BEGIN EMPLOYMENT:
CURRENT SALARY: / SALARY DESIRED:
ARE YOU EMPLOYED NOW? /  yes
 no
IF EMPLOYED, AND YOU ARE UNDER 18, CAN YOU FURNISH A WORK PERMIT? /  yes
 no
ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED IN THIS COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS?
(Proof of citizenship or immigration status will be required upon employment) /  yes
 no
HAVE YOU BEEN CONVICTED OF A FELONY WITHIN THE LAST SEVEN YEARS? /  yes
 no
IF YES, PLEASE EXPLAIN
EMPLOYMENT AND EDUCATION
Please complete all items if not on resume.
CAN YOU PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB FOR WHICH YOU ARE APPLYING, WITH OR WITHOUT REASONABLE ACCOMODATIONS? /  yes
 no
MAY WE CONTACT YOUR PRESENT EMPLOYER? /  yes
 no
NOTE: Where Larned Veterinary Clinic is asked to defer contacting your current employer, it is our practice that a routine verification of employment may be made of any employer not contacted during the application process (at the request of the applicant) subsequent to the offer and acceptance of employment, and, if it is disclosed that the applicant withheld or distorted relevant information in this regard, this may lead to immediate dismissal.
DATES EMPLOYED / EMPLOYER NAME, ADDRESS, PHONE NUMBER & MANAGER’S NAME / STARTING & ENDING SALARY / POSITION / REASON FOR LEAVING
From:
To:
From:
To:
From:
To:
EDUCATION / NAME & LOCATION OF SCHOOL / MAJOR/AREAS of STUDY / DATE GRADUATED
High School / YES
NO
College
University/
Other School/
Education
I understand and accept that if an offer and acceptance of employment is made by Larned Veterinary Clinic, there is no implied contract and my employment is not for any definite period of time, but may be terminated by me or by Larned Veterinary Clinic at any time and for any reason which is not specifically prohibited by State or Federal law. I further understand that my employment may be terminated by Larned Veterinary Clinic, in its sole discretion, if I have misstated, misrepresented or omitted any material fact in my application for employment or in any related documentation or information provided by me, whether verbally or in writing, to Larned Veterinary Clinic.
I also understand that if employed, I am required to abide by all policies, rules and regulations of the Company. Whereas, the employer has the rights to make unilateral changes in its policies, rules and regulations at any time.
SIGNATURE / DATE
Applicants are considered without regard to race; creed; color; national origin; sex; age; disability; marital status; sexual orientation; citizenship status; the presence of non-job related medical condition or disability or any other legal protected status.
All employment offers are contingent upon a satisfactory reference check.

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3/18/99