MAE Physicians Surgery Center, LLC

Careers

 Experienced Operating Room RN Positions Available

Application for Employment

Physicians Surgery Center offers equal opportunity for employment to all applicants without regard to race, creed, age, color, religion, sex, military status, disability, or national origin. In answering the following questions, I understand that PSC is relying upon the truthfulness and completeness of my statements and further understand that this reliance is a substantial factor in considering my proposed employment with PSC. This employment application is valid for 90 days.

PSC is a smoke-free environment.

Employment Information Position Applied for: ______________________ Today's Date: ___________

Type of Employment: Full________
Part________

Desired Income: __________

Days and Hours Available if Part Time:
(Show days and hours, AM and PM)

Last Name:___________________ First Name:___________________ Middle Name:__________________
Maiden Name_____________________
Address: ________________________________
  ________________________________

City:____________________State:________Zip:______

Day Telephone:______________ Evening Telephone:______________ Alternate Telephone:____________

EMail Address:__________________________

Social Security Number: ________________________
(You must have a Social Security Card in your current name to be hired.)

License, Registration or Certification #: ________________________

(If listed in qualifications for job. Proof of license, registration or certification must be presented before an offer of employment will be made.)

Do you have a reliable means of transportation to work? Yes_________ No__________

Have you ever been discharged or requested to resign from a job? Yes________No _________
If so, explain: _______________________________________________________________
_______________________________________________________________________________

Does your present employer know of your plans to change employment? Yes_______No _______

If presently employed, why do you wish to change jobs?
_______________________________________________________________________________
_______________________________________________________________________________

Do you have relatives or friends employed here? Yes_______No _______
If so, give names and relationship:______________________________________________________
_______________________________________________________________________________

Have you been employed here before? Yes_____No _____
If so, please give dates of employment:_________________________________________

Are you a U.S. Citizen? Yes_______No _______

Have you ever been convicted of a felony? Yes_______No _______
If so, explain:___________________________________________________________________
_______________________________________________________________________________

List any experience, skills or qualifications which you feel would especially suit you for work here: _______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Education Information

School Date Completed Degree/Maj. Name of School Location
High _____________ ___________ _______________ ___________
Trade,Bus.
Technical
_____________ ___________ _______________ ___________
College _____________ ___________ _______________ ___________
Nursing School _____________ ___________ _______________ ___________

Describe any other specialized or professional training. Include study courses given through private or public employment. State whether degree or certificate was received.
_______________________________________________________________________________
_______________________________________________________________________________

Can you submit copies of certificates, degrees, or awards if asked? Yes_______No _______

Employment Record

(Start with most recent or present employer)

1. Name of Present or Most Recent Employer:________________________________________________
Telephone:____________________ Last Name at Time of Employment:__________________________
Immediate Supervisor Name: _________________Immediate Supervisor Position: __________________
Your Job Title:_______________Date Hired:___________ Starting Rate:__________Date Left:_______
Last Rate:___________Duties:___________________________________________________
Reason For Leaving:___________________________________________________________

2. Name Employer:____________________________________________________________
Telephone:_____________ Last Name at Time of Employment:______________________
Immediate Supervisor Name: _______________Immediate Supervisor Position: ___________
Your Job Title:_____________Date Hired:_________ Starting Rate:________Date Left:_____
Last Rate:___________Duties:___________________________________________________
Reason For Leaving:___________________________________________________________

3. Name Employer:___________________________________________________________
Telephone:_____________ Last Name at Time of Employment:______________________
Immediate Supervisor Name: _______________Immediate Supervisor Position: ___________
Your Job Title:_____________Date Hired:_________ Starting Rate:________Date Left:_____
Last Rate:___________Duties:___________________________________________________
Reason For Leaving:___________________________________________________________

4. Name Employer:____________________________________________________________
Telephone:______________ Last Name at Time of Employment:______________________
Immediate Supervisor Name: _______________Immediate Supervisor Position: ___________
Your Job Title:_____________Date Hired:_________ Starting Rate:________Date Left:_____
Last Rate:___________Duties:___________________________________________________
Reason For Leaving:___________________________________________________________

Personal References

(No former employers or relatives)

1. Name:____________________Telephone:________________Years Known:_____________________
Address:____________________City:________________State:__________Zip:_______________

2. Name:____________________Telephone:________________Years Known:________________
Address:_______________________City:________________State:__________Zip:____________

3. Name:________________________Telephone:________________YearsKnown:____________
Address:____________________City:________________State:__________Zip:________________

AGREEMENT

Please read the following carefully:

I certify that the above information is correct and that PSC is relying upon my truthfulness and completeness in my statements and that this reliance is a substantial factor in considering my application for employment with PSC.

I understand that any misrepresentation on this application will be cause for immediate dismissal if hired.

If employed, I agree to allow PSC to payroll deduct any outstanding monies owed to this organization.

If employed, I agree to abide by all requirements, which are established or amended by PSC.

I understand and agree, if hired, my employment is for no definite period of time and may be terminated at any time.

I understand I may not be considered for employment if my application is deemed incomplete.

I understand PSC is a smoke-free environment. Any violations of this guideline will lead to discipline up to and including termination.

I hereby state that I am legally entitled to accept employment in the United States.

Under the provisions of the Fair Credit Reporting Act U.S.C., Sec. 1681, et seq. notice is hereby given that a consumer report or investigative consumer report may be made which may include information pertaining to your employment history, education background, credit worthiness, character, general reputation, driving record, criminal record, personal characteristics, and mode of living, which will be used for employment purposes.

You are further advised under said act that any person who procures or causes to be prepared an investigative consumer report on any consumer shall, upon written request by the consumer within a reasonable period of time after the receipt by him of the disclosure required by subsection 1681 (d), shall make a complete and accurate disclosure of the nature and scope of the investigation requested. This disclosure shall be made in writing, mailed or otherwise delivered, to the consumer five days after the date on which the request for such disclosure was received from the consumer or such report was first requested, whichever is the latter.

You are further advised that if you are denied employment, either wholly or partly, because of information contained in a consumer report as that term is defined in the Fair Credit Reporting Act, that a disclosure will be made to you of the name and address of the consumer reporting agency making such report.

I authorize PSC or it's agents to investigate all information and references given within and further I release PSC and all former employers or organizations from any liability whatsoever for providing the information for the investigation.

_____________________________ ____________________________
Signature Date

 


Keep up the great work. The service, staff, and physicians were excellent.

B.D.