Employment Application   Utah Cancer Specialists Employment Application An Equal Opportunity Employer Qualified applicants receive equal consideration. No question is asked for the purpose of excluding any applicant due to race, color, national origin, religion, age, sex, disability, or any other factor prohibited by law or regulation.     Please fully and accurately complete each question. Incomplete applications may not be considered.     You are applying for: Physician Asst/Nurse Practitioner - BMT   PERSONAL IDENTIFICATION   First Name:   Last Name:   Address:   City:   State:   Zip:   Home Phone:   Cell Phone:       WORK PREFERENCE   Position Desired:   Salary Expected:   Date Available For Work:       Describe your prior experience related to this work       Describe any formal schooling or training related to this work       List any licenses, certificates or professional affiliations you may have       List any special skills you may have - computer, machines, etc.           AVAILABILITY FOR WORK       Type of Work Part Time   No Yes Will you work overtime if needed? No Yes Full Time   No Yes Will you work extra days if needed? No Yes Are you now or do you expect to be engaged in any business, employment or personal commitment which could affect your work schedule?   No Yes     PRESENT EMPLOYMENT   Are you currently employed?   No Yes Do you need to give advance notice to your present employer?   No Yes May we contact your present employer for a reference?   No Yes     PERSONAL   Where did you hear about this job opening?   Are you at least 18 years of age   No Yes If hired, can you furnish proof that you are eligible to work in the US?   No Yes Have you ever been refused a surety bond or every had one cancelled?   No Yes     PRIOR EVENTS   Have you ever worked for or applied for work at Utah Cancer Specialists before?   No Yes Have you ever been discharged for cause?   No Yes In the past 7 years have you been convicted of any law violation, except a minor traffic violation? ( A criminal record does not automatically bar employment)   No Yes Explanation for answers given above       EDUCATION AND TRAINING   "High School or GED"   School Name & Location   Dates attended From:            To: "Did you receive a diploma?"   No Yes "Grade Point Average"   Subjects       College or University   School Name & Location   Dates attended From:            To: "Did you receive a diploma?"   No Yes "Grade Point Average"   Subjects       Graduate School   School Name & Location   Dates attended From:          To: "Did you receive a diploma?"   No Yes "Grade Point Average"   Subjects       Other Education   School Name & Location   Dates attended From:            To: "Did you receive a diploma?"   No Yes "Grade Point Average"   Subjects       EMPLOYMENT RECORD Give a complete account of your employment. (BEGIN WITH YOUR PRESENT OR MOST RECENT POSITION, AND WORK BACK). Employer   Address   Phone   Supervisor   Main duties   Dates From:       To: Wages Starting Pay:       Ending Pay: Reason for leaving       Employer   Address   Phone   Supervisor   Main duties   Dates From:       To: Wages Starting Pay:        Ending Pay: Reason for leaving       Employer   Address   Phone   Supervisor   Main duties   Dates From:       To: Wages Starting Pay:          Ending Pay: Reason for leaving       Employer   Address   Phone   Supervisor   Main duties   Dates From:       To: Wages Starting Pay:        Ending Pay: Reason for leaving       4. Other positions (including periods of military / public services) Employer Main Duties Employment Date From:            To: Pay Reason For Leaving     Employer Main Duties Employment Date From:            To: Pay Reason For Leaving     Employer Main Duties Employment Date From:            To: Pay Reason For Leaving     Employer Main Duties Employment Date From:            To: Pay Reason For Leaving     APPLICANT AGREEMENT (Read carefully before submitting). "All information provided by me is true and correct to the best of my knowledge. I understand omissions or misrepresentations may result in rejection of my application or, if employed, may result in subsequent dismissal. I hereby authorize any former employer, person, school, firm or corporation listed herein, including Utah Cancer Specialists, to answer any and all questions related to employment and agree to release from liability and hold all persons harmless for giving any and all truthful information within their knowledge or records. I understand this is a preliminary application and not a contract to employ me. Furthermore, in the event I am employed, my employment shall be completely voluntary and may be terminated at will at any time by either myself or the company. I understand that no one other than the Chief Executive Officer has authority to enter into any employment agreement to the contrary. I agree to take a job-related physical examination and/or a drug/alcohol test when requested as a condition of employment. I agree to comply with all rules of the company as a condition of employment. In the event the company advances me money or other things of value, I agree to repay the company and also that any amount still owing my be deducted from my final paycheck." Date I Agree!