Employment Information | Southlake Crossing Animal Clinic

Date*

Name*

First Last

Email

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Alt. Phone

U.S. Citizen?*

Yes
No

If Not a U.S. Citizen, do you have work papers?

Yes
No

Type of Employment (Please Check All That Apply)

Hours*

Full Time
Part Time
Permanent Time

Days Available*

Other (Please Explain)

Hours avaliable (00:00 to 00:00)*

Employment Desired

Position*

Date you can start*

Salary Desired*

Have you applied here before?*

Yes
No

Are you currently employed?*

Yes
No

If so, May we inquire with your present employer?*

Yes
No

Education History

Highschool (Name)

Years Attended

Did you graduate?*

Yes
No
Still Attending

College (Name)

Years Attended

Subjects Studied

Did you graduate?*

Yes
No
Still Attending

Trade, Business or Correspondence School

Subjects Studied

Did you graduate?

Yes
No
Still Attending

Why did you choose to apply here?

General Information (special studies that may be beneficial for employment at our facility)

U.S. Military or Naval Service (Please include Rank)

Past Employment

Please fill out completely, even if attaching a resume. List below the last three employers, starting with the most recent.

Past Employment

Employer Name and Location	Position	Starting Date (Month)	Ending Date (Month)	Reason for leaving	Salary Begin	Salary End

References

Name	Phone Number	Business	Years Known

Authorization

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements in this application shall be grounds for dismissal. I authorize investigation of all statements contained here in and the references and employers listed above to give you any and all information concerning my previous employment and my pertinent information they may have, personal or otherwise, release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to foregoing, unless it is in writing and signed by an authorized company representative. This waver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities act(ADA)and other relevant federal and state laws. All potential employees are evaluated without regard to race, color, religion, gender, national origin, age, marital status, veteran status, the presence of a non-job related handicap or any other legally protected status.

Signature*

Please type full name.

Date*