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During the past five years, have you had any periods of unemployment?
May we contact your current employer?
During the past seven years, have you ever been discharged, suspended or asked to resign for any reason from any position?
For the purpose of verifying information on this application, have you ever worked or attended school under a different name at any of the organizations/institutions you have listed?
Within the past ten years, have you been convicted of a crime other than misdemeanor traffic violations?
(Having a criminal record, other than misdemeanor traffic violations, does not necessarily mean you will be denied employment.)
List all employment for the past five years, starting with the most recent or present employer. Resumes should not be substituted for completing this employment record.
I hereby certify that the information given by me is true in all respects. I authorize West Wichita Family Physicians, P.A. and its representatives to contact my current and prior employers and all persons and entities for the purpose of verification of the information I have supplied, and I hereby release West Wichita Family Physicians, P.A. and those persons and entities from any liability resulting from the information released. I authorize employers, schools and other persons named on this application to provide any information or transcripts requested. I understand that misrepresentation or omissions of facts by me are grounds for refusal to hire me or my termination of employment.
Employment with West Wichita Family Physicians, P.A. is also contingent on my providing sufficient documentation necessary to establish my identity and eligibility to work in the United States.
In the event that I am employed by West Wichita Family Physicians, P.A., I understand that I must comply with all company policies and rules.
I acknowledge and agree that my employment and compensation can be modified or terminated at any time with or without cause and with or without notice at the option of either West Wichita Family Physicians, P.A. or me. I understand that no representative of West Wichita Family Physicians, P.A. other than the President, has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, either before commencement of employment or after I have become employed, and such agreement must be in writing and signed by the President.
ENTERING MY NAME, INITIALS AND DAY BELOW IS EVIDENCE THAT I HAVE READ AND AGREE WITH THE ABOVE STATEMENTS.