Employment - Advanced Dermatology

Advanced Dermatology Employment Application

As a healthcare facility treating a large number of elderly patients, we require all employees to demonstrate proof of Covid-19 vaccination such as Excelsior Pass.
Prospective employees may be tested for illegal drug use

Name *
Last, First, Middle, (Maiden if applicable)

Email *

Today's date *

Current Address *
Address, City, State, ZIP

Length of residence *

Phone *

Social Security Number *

Age (if under 18)

Available start date *

Position applied for *

Salary desired *

Number of hours/week

Available evenings? *
Yes
No

Days/Hours available to work

No preference

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Education

High School

Mailing address

Years completed

Major/Degree

College

Mailing address

Years completed

Major/Degree

Business or Trade School

Mailing address

Years completed

Major/Degree

Professional School

Mailing address

Years completed

Major/Degree

Have you ever been convicted of a crime? *
No
Yes

If yes, provide details
Include number of convictions, nature and dates of offenses, sentences imposes, rehabilitation received.

Did you serve in the armed forces? *
No
Yes

Do you serve in the National Guard? *
No
Yes

Specialty

Entry

Discharge

Employment History (please include last 5 years)

Employer

Address

Phone

Job title

Start date

End date

Supervisor's name

Reason for leaving

Details
Jobs held, duties performed, skills learned, advancements or promotions earned, other details.

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Employer

Address

Phone

Job title

Start date

End date

Supervisor's name

Reason for leaving

Details
Jobs held, duties performed, skills learned, advancements or promotions earned, other details.

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Employer

Address

Phone

Job title

Start date

End date

Supervisor's name

Reason for leaving

Details
Jobs held, duties performed, skills learned, advancements or promotions earned, other details.

Valid drivers license? *
Yes
No

State

Drivers license number

Class
Operator
Commercial
Chauffeur

Expires

Means of transportation to and from work *

Have you had any accidents in the last 3 years? *
No
Yes

If so, how many

Have you had any moving violations in the last 3 years? *
No
Yes

If so, how many?

List two references other than relatives or previous employers

Name *

Company

Position

Address *

Phone *

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Name *

Company

Position

Address *

Phone *

It can be difficult to summarize all of your qualifications and experience on an application form. We invite you to use the space below to provide any additional details specific to the position for which you are applying.

*
I understand that Advanced Dermatology is a healthcare facility that treats many elderly and compromised patients and therefore requires their employees to receive the Covid-19 vaccination. By checking this box I agree to provide proof of vaccination prior to starting employment with Advanced Dermatology.

*
I understand that Advanced Dermatology may require testing for illegal drugs prior to employment. By checking this box I agree to submit to such testing if requested.

By clicking SUBMIT I affirm that the information provided in this application is accurate and complete. Should I become employed with Advanced Dermatology I agree that any misrepresentation made on this application could be grounds for dismissal.

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