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EMPLOYMENT APPLICATION

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Date
Company Name:
Position Applied:

Personal Data

Salary Expectations:
Name:
Street Address:
City:
State:
Zip Code:
Phone
If you are under 18 years of age, please specify your age:
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Are there any days, shifts or hours you will not work?
If yes, please explain:
Are there any days, shifts or hours you will not work?
Will you work overtime, if?

*Note: It is not necessary for you to identify unavailability for work because of religious observance or practice or any other protected classification. Subsequent to any job offer, we will consider whether a reasonable accommodation can be made.

When Can You Start Working?:
How Did You Learn Of Our Company?
Have You Ever Applied Or Worked At Our Company Before?
If Yes, Provide Dates:
Are You Legally Authorized To Work In The United States?
Will you now or in the future require sponsorship for employment visa status (e.g., H-1B visa status)?

Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification “Form I-9” be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.

DRIVING RECORD

(Answer only if driving is a requirement of the job for which you are applying).

Do You Have A Valid Driver’s License?
State:
License No:
Have You Had Any Tickets?
If yes, please explain:

EDUCATION

Describe any educational degrees, skills, training or experience you believe are relevant to the job applied for:

Graduated Type of Degree Received or Expected Mayor Minor Grade Point/ Overall GPA
Yes No

High School

Name
City
State

College or University

Name
City
State

Technical/GED

Name
City
State

Licenses/ Certification / Other

Name
City
State

EMPLOYMENT HISTORY:

Please complete for all full-time or part-time employment beginning with most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis. All applicants should start with their most recent job, include military assignments and voluntary employment and provide ten (10) years of history. (A separate sheet may be attached.) You must explain any gaps in your employment history.

Add Employment
Have you ever been discharged or asked to resign from employment?
If yes, explain:
Did you receive any discipline in your last 12 months of active employment with your previous employer?
If yes, please explain:
Were you given a performance evaluation within the last 12 months of active employment?
If yes, what was the range of scores used and what was your score?:
Have you signed any non-competition or non-solicitation agreement or any other kind of agreement with any other employer that might restrict you from working for the Company (you will be required to furnish a copy of the agreement if you are being considered for hire)?
If yes, please explain:

PROFESSIONAL REFERENCES

(Please list three individuals unrelated to you with whom you have worked who know your qualifications for this position.)

Name Address Phone Relationship

MILITARY

Do You Serve In Any Military Corps?
Branch of Service:
Number of Years /Months of Service:
Rank at Discharge:
Date of Discharge:
Describe any military skills, training or experience you believe are relevant to the job you applied for:

APPLICANT’S ACKNOWLEDGMENT

I certify that the answers given herein and during the entire application process (including but not limited to information provided in resumes, attachments to this application, interviews or otherwise (if applicable) are true and complete to the best of my knowledge.

I understand that any misrepresentations, omissions of facts or incomplete answers during the application process may disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts during the application process may be cause for my dismissal at any time without prior notice

I consent to and authorize the Company to contact my former employers, references, and any and all other persons and organizations for information bearing upon my qualifications for employment.

I EXPRESSLY AGREE AND UNDERSTAND THAT, IF EMPLOYED, MY EMPLOYMENT IS NOT FOR A SPECIFIC TERM, IS BASED ON MUTUAL CONSENT AND MAY BE TERMINATED BY ME OR THE COMPANY WITH OR WITHOUT NOTICE OR CAUSE AT ANY TIME. I FURTHER UNDERSTAND THAT NO ORAL PROMISE, EMPLOYER POLICY, CUSTOM, BUSINESS PRACTICE OR OTHER PROCEDURE (INCLUDING PERSONNEL HANDBOOK OR ANY PERSONNEL MANUALS) CONSTITUTE AN EMPLOYMENT CONTRACT OR MODIFICATION OF THE AT-WILL EMPLOYMENT RELATIONSHIP BETWEEN ME AND THE COMPANY. I ALSO UNDERSTAND THAT MY AT-WILL EMPLOYMENT STATUS WITH THE COMPANY MAY ONLY BE ALTERED IN AN INDIVIDUAL CASE OR GENERALLY IN A WRITING SIGNED BY THE OWNER, PRESIDENT OR CEO OF THE COMPANY.

I understand I may be required to qualify for employment based on additional employment criteria. For example, I may be required to take job-related tests; take a driver’s examination or take a pre-employment drug test. If I am offered employment or start work before any required test is completed, I understand that my employment is contingent on a satisfactory result on all required tests. I authorize the release of any drug/alcohol test to any state or federal authority requesting such information and in response to a valid subpoena or other legal document. I agree to sign any additional forms necessary for drug tests to be conducted.

Signature:
Date:
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Soma Medical Center, P.A.

Thank you for contacting Soma Medical Center, P.A. Please let us know how we can assist you

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Work with us

Join our team at Soma Medical Center, where we value passion, commitment, and collaboration. We offer development opportunities in an inclusive and stimulating environment. Whether you are an experienced professional or looking to take the next step in your career, we have exciting opportunities for you. Send us your resume, and together we will build a successful future. We look forward to meeting you soon!

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