Hurley Chiropractic & Wellness Center Employment Application COMPLETE ALL PAGES OF THIS APPLICATION APPLICANTS MAY BE TESTED FOR ILLEGAL DRUG USE Date of Application: PERSONAL INFORMATION Name: - - First Middle Initial Last Social Security # Current Address: Number Street Apartment # City State Zip Primary Phone Number: ( ) Cell or Home Have you ever been convicted of a crime: If yes, explain number of conviction(s), nature of offense(s) leading to convictions(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type of rehabilitation? Do you currently or have you ever served in the armed forces including the National Guard? If so, what branch? Rank Dates Do you have reliable transportation to get to work? OFFICE SKILLS Micro-Soft Office: (circle all that you are proficient in) Word Excel PowerPoint Publisher Keyboarding WPM: 10Key: Filing: Phone: Customer Service: Copy/Scan/Print: POSITION / PAY INFORMATION
Check all positions you wish to apply for: Front Desk/Patient Services Billing/Insurance Assistant Therapy Assistant Personal Trainer Massage Therapist PR/Sales Chiropractor Hourly Rate Range Desired: $ - $ OR Annual Salary Range Desired: Desired$ - $ EDUCATIONAL INFORMATION Type School of Name of School Location / Address # years attended Major Degree/certificate High School College Trade School Professional School PERSONAL REFERANCES List three references that are not relatives or previous employers
PREVIOUS EMPLOYMENT EXPERIENCE List work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary. Name of Employer: Complete Address: Phone Number: Name of supervisor: If this is your present employer may we contact for reference purposes? Name of Employer: Complete Address: Phone Number: Name of supervisor: Name of Employer: Complete Address: Phone Number: Name of supervisor:
AVAILABILITY INFORMATION Employment Desired? (Circle one) Full-Time Only Part-Time Only Either FT/PT If Part-Time, how many hours per week can you work? Days & Hours Available to Work Some positions require shift work that may include nights and weekends. (Write the hours you are available next to each day, write N/A for not available) Monday Tuesday Wednesday Thursday Friday Saturday Sunday When are you available to begin work? Day (M-F) Date Initial Date PERSONAL STATEMENT An application sometimes does not provide opportunities for individuals to adequately express their complete background and capabilities. Please us this space to add any additional information you deem necessary to describe your full qualifications for the position(s) applying for.
PLEASE READ CAREFULLY APPLICATION FORM WAIVER In exchange for the consideration of my job application by Hurley Chiropractic & Wellness Center, I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other company practices, shall serve to create and actual or implies contract of employment, or to confer any right to remain and employee of Hurley Chiropractic & Wellness Center, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President/General Manager/ HR Manager of the company. Both the undersigned and Hurley Chiropractic & Wellness Center may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction of benefits. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts call for is a cause for dismissal at any time without previous notice. I herby give the company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and herby release the company from any liability as a result of such contract. I also understand (1) the company has a criminal background check as well as drug and alcohol policy that provides for pre-employment review/testing as well as testing after employment, (2) consent to and compliance with such policy is a condition of my employment, and (3) continued employment id based on the successful passing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations. I further understand that my employment with the company shall be probationary for a period of (90) day, and further that at any time during the probationary period or thereafter, my employment relation with the company is terminable at will for any reason by either party. Signature of Applicant Date This company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this company depends solely on your qualifications. Thank you for completing this application and for your interest in Hurley Chiropractic & Wellness Center