Full Application Form

Application for Employment at Spring Creek Surgical Center
Applicants are not required to give any information that is prohibited by federal, state/provincial, or local law.
Date

Month Day Year
Social Security Number
XXX-XX-XXXX
Your Name *

First Name Middle Name Last Name
Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Number of Years lived at address above
Home Phone Number *

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Position you are applying for *
Your E-mail Address *
Please Attach Your Resume (PDF Preferred)
What type of employment are you seeking?

Full Time Part Time Temporary
When could you start employment?

What schedule are you available to work? (include a.m. or p.m.)

	From	To
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Employment Status
Are you currently employed?

Yes No
Is it your intent to continue in your current job if you work here?

Yes No
Are you currently a student?

Yes No
What impact does being a student have on your availability to work?
Are there any commitments, activities, hobbies, vacation plans, etc. that could affect your ability to work here?

Yes No
If yes, please explain:

Employment History
List the most recent employer, or last employer, first. Include military service or any self-employed or unemployed periods. You must account for the past ten (10) years or since completing school, whichever is less. Use additional pages if necessary.
Company
Address
Telephone Number

Date Employed

	.
From
To
Last Salary

Last Position Held
Last Supervisors Name
Why did you leave (be specific)
Liked most about job? (be specific)
Liked least about job? (be specific)
Do you have another 2nd Employer you'd like to add?

Yes No
Company
Address
Telephone Number

Last Position Held
Last Supervisors Name
Why did you leave (be specific)
Liked most about job? (be specific)
Liked least about job? (be specific)
Do you have another 3rd Employer you'd like to add?

Yes No
Company
Address
Telephone Number

Last Position Held
Last Supervisors Name
Why did you leave (be specific)
Liked most about job? (be specific)
Liked least about job? (be specific)

	.
High School Name
Location
Did you Graduate?
Year Graduated
GPA

References
Give names of two people, not relatives or former employees, who have known you for five years.

1st Person

	.
Name
Current Address
City/State/Zip
Home Phone
Years Known

2nd Person

	.
Name
Current Address
City/State/Zip
Home Phone
Years Known

In Case of Emergency
Name
Home Phone
Current Address
Work/Message Phone
Conditions of Employment
Spring Creek Surgical Center sets a high standard for its employees. We require compliance with these standards as a condition of employment. You need to carefully consider what will be required before considering a position with us. As an employee of Spring Creek Surgical Center you would be expected to comply in full. You need to know and understand that Spring Creek Surgical Center will require you to:

JOB EXPECTATIONS

• Meet performance standards of position

• Work hours as scheduled – report to work on time.

• Take direction from supervisors and execute that direction to the best of your ability.

• Maintain a positive, enthusiastic attitude at all times. Be a cooperative member of the staff.

• Train, as needed, to keep high performance level on your job.

PERSONAL APPEARANCE

Maintain a business-like, professional appearance (dress and grooming)
Would you be able to comply with all the requirements as listed?

Yes No
If “no” or you have any concerns about being able to comply with any of these requirements, please explain:

Acknowledgements and Agreements
ALL APPLICANTS – Please read the following and address any questions to the Personnel Representative signing below: I acknowledge that in connection with my application for employment, promotion, or reassignment with Spring Creek Surgical Center, an investigative consumer report or other inquiry may be made as to my character, general reputation, personal characteristics and mode of living. If a report is made, I have been advised further that upon written request within a reasonable amount of time, additional information as to the nature and scope of the report, if one is made, will be provided. This written request should be addressed to the Personnel Department where this application is made.

I hereby authorize all personnel, schools, companies, corporations, credit bureaus and law enforcement agencies to supply any and all information pertinent to my employment and release the same from any liability resulting from providing such information. Spring Creek Surgical Center has my permission to make said inquiries and I hereby release Spring Creek Surgical Center from any liability in making said request or in relying on the information received.

I understand that satisfactory reports are a condition of my employment with Spring Creek Surgical Center. I further understand that my employment with Spring Creek Surgical Center will be terminated if management determines that said reports are unsatisfactory.

I also acknowledge that from time to time, Spring Creek Surgical Center may be required to submit certain information with regard to my employment or application for employment. I hereby release the (Company), its agents, assigns and subsidiaries from any liability from submitting such information.

I acknowledge that Spring Creek Surgical Center may request either prior to and/or after employment that I undergo drug testing and may request after an offer has been made, a medical exam. I consent and agree to any such exam, if required, now or in the future. I understand that when pre-employment drug testing is required, a satisfactory result is a condition of employment with Spring Creek Surgical Center.

I hereby certify that all statements and answers made on this Employment Agreement are complete and true. I understand that if subsequent to employment any of such statements and/or answers are found to be false or that information is omitted, such false statements or omissions will be considered grounds for termination of my employment.
Employee Signature

Clear
Should be Empty:

Application for Employment at Spring Creek Surgical Center

Employment Status

Employment History

Education Background

Other Information

References

In Case of Emergency

Conditions of Employment

Acknowledgements and Agreements