Name:
Address:
City: State: Zip Code:
Home Phone Number: Business Phone Number:
Message Phone Number: Email:

Employment you are looking for: Full-Time Part-Time

Can you perform all of the essential functions of the position for which you are applying with or without a reasonable accomodation? Yes No
Position applied for:
Date available for employment: Salary Desired:
Would you accept another position? Yes No

Are you willing to work: Overtime (over 40 hrs/wk)=Yes No On call=Yes No Rotating shifts=Yes No Nights=Yes No Weekends (Sat/Sun)=Yes No Holidays=Yes No Travel=Yes No

Are you applying for: full time part time temporary

In accordance with the Federal Immigration and Reform Act of 1986, if you are employed by our Company you will be asked to provide documentation that verifies your legal right to work in the United States. If you cannot provide acceptable documentation, we cannot legally employ you.

Can you provide such documentation? Yes No

Have you ever been convicted of a felony? Yes No
If yes, please explain. Conviction does not automatically exclude you from consideration for employment

If you are hired or transferred into a position that requires the operation of a vehicle, we will require a DMV investigation. Do you authorize investigation of your DMV record? Yes No

Driver's License Number State Expiration Date of License

If under 18 years of age, can you submit a work permit after employment? Yes No N/A

Do you have any commitments to another employer that might affect your employment with us?
If yes, please explain

Do you authorize a background investigation including prior employers, education, and criminal records? Yes No

Education

	Name/Location	Subjects/Studies	Degrees or Credits
High School
Junior College/Trade School
University/College
Graduate School
Professional Licenses or Certificates

Other training skills including bi-lingual ability:

Previous Experience

Please list name, address and phone number of previous employers with most recent employer first, also include military experience and service training. Periods of unemployment should be included.

Job title from to
Immediate Supervisor
Last Salary: Hourly, Monthly or Yearly
Employer name, address & telephone
Duties
Reason for leaving
May we contact now? Yes No

Job title from to
Immediate Supervisor
Last Salary: Hourly, Monthly or Yearly
Employer name, address & telephone
Duties
Reason for leaving
May we contact now? Yes No

Job title from to
Immediate Supervisor
Last Salary: Hourly, Monthly or Yearly
Employer name, address & telephone
Duties
Reason for leaving
May we contact now? Yes No

Military service? Yes No
If yes, from to
Branch of service
Highest rank obtained

References

May we run an employment check from the employers listed above? Yes No

Has notice been given to present employer? Yes No

Is there any additional information relative to change in name necessary to check your work history? Yes No
If yes, please explain

Please list references (not relatives or employers) to contact who are acquainted with your work history. Do not include personal references.

Name:
Title/Occupation:
Company/Address:
Telephone number:

Name:
Title/Occupation:
Company/Address:
Telephone number:

Name:
Title/Occupation:
Company/Address:
Telephone number:

Remarks

Please include any other information you think would be helpful to us in considering you for employment, such as additional work experience, publications, activities, accomplishments, etc. (You may exclude all information indicative of age, sex, race, religion, color, national origin or handicap.)

THE FOLLOWING POINTS ARE VERY IMPORTANT. PLEASE READ THEM CAREFULLY BEFORE AGREEING TO THIS APPLICATION
I authorize investigation of all statements contained in this application. I will not hold Yankton Medical Clinic, P.C. or any of my previous employers liable in any respect if an employment offer is not forthcoming, is withdrawn, or if my employment is terminated as a result of misrepresentation or omission of facts on this application. I understand that if I am employed by Yankton Medical Clinic, P.C. additional personal data may be required for determination of benefits, statistical purposes, and legal compliance. I also understand that if I am employed by the Clinic, my employment is "at will", that I or the Clinic may terminate the employment relationship at any time, for any reason, with or without notice. I further understand that no employee of the Clinic has the authority to modify the understanding orally or in writing, except with the written permission of the Executive Director of The Yankton Medical Clinic, P.C.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE STATEMENTS AND UNDERSTAND EACH AND ALL OF THESE STATEMENTS. ALL APPLICATIONS KEPT ON FILE FOR 12 MONTHS.

I agree I disagree