Employment Application

Position Sought *

How did you learn of this position?

Date

First Name *

Last Name *

Address *

City *

State

Zipcode *

Contact Phone *

Email Address *

Are you a U.S. citizen, or are you otherwise authorized to work in the U.S. without restriction? *YesNo

Have you ever been arrested or convicted of a felony or misdemeanor other than minor traffic violation? *YesNo

If yes, please describe the circumstances0 / 600

Have you ever been involuntarily terminated or asked to resign from any position of employment? *YesNo

If yes, please describe the circumstances0 / 600

If selected for employment, are you willing to submit to pre-employment drug screening test? *YesNo

Are you willing to undergo a background check? *YesNo

Education

School 1

School 1 Name *

School 1 Location *

School 1 Years Attended *

School 1 Degree Received

School 1 Major

School 2

School 2 Name

School 2 Location

School 2 Years Attended

School 2 Degree Received

School 2 Major

School 3

School 3 Name

School 3 Location

School 3 Years Attended

School 3 Degree Received

School 3 Major

School 4

School 4 Name

School 4 Location

School 4 Years Attended

School 3 Degree Received

School 4 Major

Other Information

Other training, certifications, or licenses held0 / 600

List Other information pertinent to the employment you are seeking0 / 600

Employment History

Start with Your Most Recent Employer First

Employer 1

Employer *

Job Title *

Dates Employed *

Prior Position *

Employer Address *

City *

State

Zipcode *

Employer Phone *

Starting Salary

Ending Salary

Supervisor *

Duties Performed *0 / 600

Reason for Leaving *

Employer 2

Employer

Job Title

Dates Employed

Prior Position

Employer Address

City

State

Zipcode

Employer Phone

Starting Salary

Ending Salary

Supervisor

Duties Performed0 / 600

Reason for Leaving

Employer 3

Employer

Job Title

Dates Employed

Prior Position

Employer Address

City

State

Zipcode

Employer Phone

Starting Salary

Ending Salary

Supervisor

Duties Performed0 / 600

Reason for Leaving

References

Three Professional References

Professional Reference 1

Professional Reference 1 Name *

Professional Reference 1 Company Name *

Professional Reference 1 Title *

Professional Reference 1 Phone *

Professional Reference 2

Professional Reference 2 Name

Professional Reference 2 Company Name

Professional Reference 2 Title

Professional Reference 2 Phone

Professional Reference 3

Professional Reference 3 Name

Professional Reference 3 Company Name

Professional Reference 3 Title

Professional Reference 3 Phone

One Personal Reference

Personal Reference Name *

Personal Reference Company Name

Personal Reference Title

Personal Reference Phone *

Additional Information

Have you applied with Medical Park Family Care, Inc previously? *YesNo

If So, When?

For what position did you apply?

Do you have any family currently working for Medical Park Family Care, Inc? *YesNo

If Yes, Who?

Family Member Job Title

Additional Information or further explanation(s):0 / 600

Acknowledgement and Authorization

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

All applicants understand they are to perform in accordance with HIPAA Privacy Compliance and Hitech Act regulations of the U.S. Department of Health and Human Services.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. Employment will be pending a complete and satisfactory Interested Persons Report obtained by the applicant within 15 days prior to hire.

Name *

Date *

Please Acknowledge and Agree to the Above *I Agree

Resume

To be considered for a position with MPFC, please complete our online application and submit a resume.

You can attach a resume to this application with the button below. (Must be pdf format less that 5MB)

Alternately they can be faxed or emailed. Faxed or emailed resumes should be directed to our Human Resources Coordinator, Chris Deptula, via fax (907-257-8185) or email at cdeptula@mpfcak.com. Resumes submitted without an accompanying online application will not be considered.

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Must be pdf format less that 5MB

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