Helmwood Veterinary Clinic - Application for Employment

Offering Care and Services That are "A Step Ahead"

Application for Employment

Application for Employment

Position you are applying for:

PERSONAL INFORMATION

Name:
(LAST, FIRST, MIDDLE)

Email:

Home Phone:
(### ###-####)

Business Phone:

ext.:

Address:

City:

State:

Zipcode:

S.S. #:

Are you at least 18?: Yes No
(If no, please show work permit)

Do you have the legal right to work in the U.S.?: Yes No

Have you previously worked with animals? In what capacity?:

Please list your office skills (i.e. typing, computer, bookkeeping, etc.):

Please list your clinical skills (i.e. blood collection, microscope, etc.)

Education	School Name	No. of Years Attended	Did you graduate?	Course or Major
Junior High:
High School:
College:
Special Courses or Training:

Certificates or Licenses
Type of Cert. / Lic.	License #	Date Earned	State Issued	Current Through (give date)

Do you have experience in the position that you are applying for?

Can you meet the attendance requirements of the job?

Do you have the required license(s) to perform this job?

Do you illegally use drugs?

I can work: Days Evenings; From To ;
No. of days per week ; No. of hours per week

Select the days of the week you will not be able to work:
Mon. Tues. Wed. Thurs. Fri. Sat. Sun.

Date available to start?

Salary requirement: Hr., Mo.

Fringe Benefits required?

Have you ever been vaccinated for Hepatitis B?

Have you ever been convicted of a crime other than a traffic violation?
(NOTE: A conviction is not an automatic bar to employment.) If yes, please explain:

EMPLOYMENT / WORK EXPERIENCE
Cover last 7 years, include periods of self-employment, or unemployment. Answer all questions here and throughout this employment application form. If additional space is needed, please use the box labeled "Additional Employment Information" below the last employment question.

List present or most recent position first

Name of employer:

Address:
City:
State: Zipcode:

Phone #:

Employed (Month and Year): From ; To

Position(s) held:

Supervisor's Name and Title:

Average number of hours worked per week:

Rate of Pay: Start ; Ending

Your last name at time of employment:

Describe your duties:

May we contact this employer?

Give specific reason for leaving:

Name of employer:

Address:
City:
State: Zipcode:

Phone #:

Employed (Month and Year): From ; To

Position(s) held:

Supervisor's Name and Title:

Average number of hours worked per week:

Rate of Pay: Start ; Ending

Your last name at time of employment:

Describe your duties:

May we contact this employer?

Give specific reason for leaving:

Name of employer:

Address:
City:
State: Zipcode:

Phone #:

Employed (Month and Year): From ; To

Position(s) held:

Supervisor's Name and Title:

Average number of hours worked per week:

Rate of Pay: Start ; Ending

Your last name at time of employment:

Describe your duties:

May we contact this employer?

Give specific reason for leaving:

Additional Employment Information:

An Equal Opportunity Employer

GENERAL AGREEMENT
I understand that all offers of employment are conditioned on receipt of satisfactory responses to reference requests and the provision of satisfactory proof of the applicant's identity and legal authority to work in the United States. In consideration of my employment, I agree to conform to the rules and standards of the practice, as amended from time to time at the employers discretion.

AUTHORIZATION TO CHECK REFERENCES
I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the information checked unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals whom the practice may contact, to provide all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from all liability for any damages that may result for furnishing the practice with such information as well as from the use and disclosure of such information by the employer or any of its agents, employees or representatives. I understand that any misrepresentation, falsification, or omission of material information on this application may result in my failure to receive an offer, or, if I am hired, my dismissal from employment.

EMPLOYMENT RELATIONSHIP
If employed, I understand that employment with the practice is not for a specified term and can be terminated "at will", with or without notice, at any time, either at the option of the employee or the employer. The "At-Will" employment policy includes all employees including those presently employed by the practice. No employee or representative of the practice, other than its owner, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Further, the employer may not alter the "At-Will" nature of the employment relationship unless it is done specifically and in writing that is signed by the employer. I agree that this constitutes a final and fully binding agreement with respect to the "At-Will" nature of my employment relationship. There are no oral or collateral agreements regarding this issue.

Applicant's signature:

Date:

Application forms will be retained for a period of three months.

Helmwood Veterinary Clinic
804 North Dixie Ave
Elizabethtown, KY 42701
phone: 270-737-1818

Hours of Operation:
M,W,Th,F: 7:30AM - 6PM
Tues: 7:30AM - 8PM
Sat: 8AM - 2PM
Office hours are by appointment.

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