Harmony Center for Ear, Nose & Throat - ENT employment application

We are an equal opportunity employer and will not discriminate on the basis of race, color, sex, sexual orientation, gender identity, national origin, age, religion, marital or veteran status, the presence of a medical condition or disability, height, weight, arrest record or any other protected status in the hiring, payment, discipline or promotion of employees.

Employers must make accommodations to disabled applicants and employees where the accommodation does not impose an undue hardship on the employer. Under Michigan law, disabled applicants and employees may request an accommodation on their disability by notifying the firm in writing of the need for accommodation within 182 days of the date the disabled individual knows or should know that an accommodation is needed. Failure to properly notify the Practice may preclude any claim that the employer failed to accommodate the disabled individual.

Name(Required)

Date of Application

Email(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Are you 18 years or older?(Required)

Yes

Are you legally eligible for employment in the US?(Required)

Yes

Have you been previously employed here?(Required)

Yes

If Yes, date(s)

List friends or relatives working here(Required)

Do you have a reliable method for getting to work?(Required)

Yes

Do you have a valid driver's license?(Required)

Yes

Position applied for(Required)

Full Time

Part Time

Other

Referral Source (how did you hear about us?)

Do you have any special training, skills, qualifications or other experiences that relate to the position applied for?

If Yes, describe

Days available to work

Times available to work

Mon

Tue

Wed

Thurs

Fri

Sat

Sun

Will you work overtime if asked?(Required)

Yes

When will you be available to begin work?(Required)

What is the Salary/Hourly wage you desire?(Required)

EMPLOYMENT HISTORY

Employer

Address

Job Title

Responsibilities

Supervisor

Reason for Leaving

Dates Employed

From

Employer

Address

Job Title

Responsibilities

Supervisor

Reason for Leaving

Dates Employed

From

Employer

Address

Job Title

Responsibilities

Supervisor

Reason for Leaving

Dates Employed

From

EDUCATION

High School

Name/Location

Years Completed

Degree

Course of Study

College

Name/Location

Years Completed

Degree

Course of Study

Other

Name/Location

Years Completed

Degree

Course of Study

REFERENCES

Name

Address

Phone

Years Acquainted

Name

Address

Phone

Years Acquainted

Name

Address

Phone

Years Acquainted

Have you had any experience in the Armed Forces of the United States or in a State National Guard?

Yes

If yes, what branch

Special training

Are you in the reserves?

Yes

If yes, date obligation ends

Special training

AUTHORIZATION AND UNDERSTANDING
Upon the signing of the application, I represent that all of the information now or hereafter given by me in support of my application is true and complete. I authorize you to verify any of the information concerning my employment with the appropriate individuals, companies, institutions or agencies, and I authorize them to release such information as you require, including my prior disciplinary employment record, without any obligation to give me written notice of such disclosure. I here by release you and them from any liability whatsoever as a result of any such inquiries and disclosures. I agree that any false information in support of my application may subject me to discharge at any time during the period of employment.

AT WILL STATUS: In consideration of my employment, I agree to conform to the rules and regulations of the Practice, and my employment and compensation can be terminated at-will with or without cause and with or without notice at any time, at the sole discretion of the Practice or myself. I agree that no one other than Kenneth L. Gwinn, M.D, F.A.C.S. has any authority to enter into any agreement or contract for any specified period of time, or to make any agreement contrary to the foregoing. I agree that either party may terminate the employment relationship, with or without cause, at any time, and I further agree that this arrangement may only be altered in writing directed to me personally and signed by Kenneth L. Gwinn, M.D, F.A.C.S . I agree that I shall be bound by the other rules, policies, regulations and terms and conditions of employment of the Practice as they are from time to time changed, and no additional obligations can be imposed on the Company except those which have been acknowledged in writing by Kenneth L. Gwinn, M.D, F.A.C.S or designated representatives.

CLAIMS: I agree that, to the extent permissible by law, any action or suit against the firm arising out of my employment or termination of employment, including, but not limited to claims arising under state or federal civil rights statutes, must be brought to the Michigan Department of Civil Rights within 180 days of the event giving rise to the claims or be forever barred. I waive any limitation periods to the contrary. I further agree that if I should bring any non-statutory action or claim arising out of my employment against the Practice, in which the Practice prevails, I will pay to the Practice any and all such costs incurred by the Practice in defense of said claims or actions, including attorney fees. I further agree that my employment is conditional until such time as the results of my post-offer pre-employment screens are known.

I CERTIFY THAT ALL INFORMATION PROVIDED ON THIS APPLICATION IS TRUE, COMPLETE, AND CORRECT. I FURTHER UNDERSTAND AND AGREE ANY FALSIFICATION, MISREPRESENTATION OR OMMISSION OF FACT ON THIS APPLICATION OR IN SUBSEQUENT INTERVIEWS ARE GROUNDS FOR DISQUALIFICATION FOR CONSIDERATION OF EMPLOYMENT AND FOR IMMEDIATE DISMISSAL OF EMPLOYMENT IF THE DISCOVERY IS MADE AFTER EMPLOYMENT BEGINS.

Signature

Date