Employment Application Employment Application Step 1 of 5 20% Employment Application Dr. Clint Vanlandingham D.P.M, M.S. 225 Physicians Park Dr. Suite 102 Poplar Bluff, MO 63901Name* Social Security Number Present Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneBusiness PhoneEmail Address Position Applied For Date available for employment Salary Desired Would you accept another job Yes No Are you willing to work; please mark all that apply: Overtime (over 40 hrs/wk) On Call Rotating Shifts Nights Weekends (Sat./Sun.) Holidays Travel Typing WPM: Shorthand WPM: Keypunch SPH: Word Processor system: Transcription (yes or no): Other Job Related Skills: Are you applying for: Full Time Part Time Temporary How were you referred to this organization? Do you have any relatives working for this organization: Yes No If yes, name: Relationship Department Have you ever been employed by this organization? Yes No If yes, position: Department From _______to_________: Are you willing to provide necessary documentation to establish your identity and your authorization to work in the United States under the Immigration Reform and Control Act of 1986? Yes No Are you older than 18? Yes No After a conditional offer of employment, are you willing to undergo a physicalexam? Yes No Do you have any commitments to another employer that might affect your employment here? If yes please explain. Since reaching 18, have you ever been convicted of a misdemeanor or felony? (Note: convictions will not necessarily bar you from employment, but are reviewed as related to the relevancy of the job applied for.) Yes No If yes, please explain Military Service? Yes No From _________ to ______________: Branch of Service: Highest Rank Earned High School Name and Address Last year completed Did you graduate (yes or no)? Diploma Received? College Name and Address Course of Study Did you graduate (yes or no)? Degree Received College Name and Address Course of Study Did you graduate (yes or no)? Degree Received Business, Technical, or Professional School Name and Address Course of Study Did you graduate (yes or no)? Degree/Certificate Received Professional Licenses/Certifications Type State Expiration Date Registration Number Type State Expiration Date Registration Number If selected for an interview, you will review job functions and answer the following questions at that time:After reviewing the functions of the job for which you are applying, are you able to perform these functions without reasonable accommodation? Yes No If you are not able to perform the tasks without reasonable accommodation, how would you perform the task, and what accommodation would be needed? Job Title Employer Name, Address & Phone Number: Duties Reason for Leaving Job Title Employer Name, Address & Phone Number: Duties Reason for Leaving Job Title Employer Name, Address & Phone Number: Duties Reason for Leaving May we obtain a credit rating? Yes No May we run an employment check from the employers listed above? Yes No Has notice been given to your present employer? Yes No Is there any additional information relative to change in name necessary to check your work history? Yes No If yes, please explain: Please list references (not relatives or employers) to contact who are acquainted with your work history:Name Title/Occupation Company Address Telephone # Name Title/Occupation Company Address Telephone # Name Title/Occupation Company Address Telephone # Please include any other information you think would be helpful to us in considering you for employment, such as additional work experience, publications, activities, accomplishments, etc. (You may exclude all information indicative of age, sex, religion, color, national origin, or handicap).Add Resume (if applicable)Max. file size: 64 MB.I hereby affirm that the information on this applications (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. I understand that my employment may be terminated, with or without cause, at any time at the discretion of my employer or myself. I understand that no management official other than the chief executive officer of the employer has any authority to enter into agreement contrary to the foregoing or to make any oral assurance or promise of continued employment to me. I authorize persons, schools, my current employer (if applicable), and previous employers and organizations named in this application (and accompanying resume, if any) to provide any relevant information that may be required to arrive at an employment decision. Signature Date Δ
