Who should be contacted if you are involved in an emergency?

  Full or Part Time?

List any skills that may be useful for the job you are seeking. Enter the number of years of experience, and circle the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)

List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment. If additional space is needed, continue on the back page of this application.

List any two non-relatives who would be willing to provide a reference for you.

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize Quality Family Medical Clinic to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its CEO/CFO, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Quality Family Medical Clinic, except in a specific written contract of employment signed on behalf of the organization by its CEO/CFO, has the power to alter or vary the voluntary nature of the employment relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS