American Medical Inc.

LOGO

Dear Applicant,

Welcome!

As there are many employment opportunities that you could have chosen, we thank you for considering American Medical Inc. Our goal is to assist you, maintain, and enhance your professional skills.

Whether you are joining our staff as full, part time, or per diem, we aim to provide you with comparable salary rates. Please feel free to ask any questions regarding this application process.

Again, thank you for considering our company, and Welcome to our family.

Sincerely,
The Family of American Medical Inc.
d/b/a/ American Medical Management of New York

Personal Information

First Name*:

(Required)

Last Name*:

(Required)

Social Security Number (last 4 numbers only):

Phone Number:

Cellular Number:

Email Address*:

(Required)

Birth Date:

Present Address

Permanent Address:

Address Line 1:

Address Line 2

City:

State:

Zip Code:

Country:

Desired Employment

Position Desired:

Salary Desired:

Date You Can Start:

Are You Employed Now?

If so, May We Inquire of Your Present Employer?

Ever Applied To This Company:

Where / When

Ever Worked For This Company:

Where / When

Reason for Leaving:

Name of Last Supervisor at This Company:

Who Referred You To This Company?

Education

Licenses you currently hold:

(1)

(2)

(3)

Name & Location of School

No. of Years Attended

Did You Graduate

Subjects Studied

Grammar School

High School

Trade, Business or Correspondence School

Years Attended

School/College/University

Degree

Course

From

Special Skills and Training

Subjects of Special Study or Research Work:

Special Training:

Special Skills:

Employment History

(Please start withj your most recent employer)

(1) Employer Name

Job Title:

Employer Phone Number:

Starting Date:

Leaving Date:

Employer Address:

Job Responsibilities:

(2) Employer Name

Job Title:

Employer Phone Number:

Starting Date:

Leaving Date:

Employer Address:

Job Responsibilities:

(3) Employer Name

Job Title:

Employer Phone Number:

Starting Date:

Leaving Date:

Employer Address:

Job Responsibilities:

References

Reference (1)

Name:

Address:

Business:

Years Acquainted:

Reference (2)

Name:

Address:

Business:

Years Acquainted:

Reference (3)

Name:

Address:

Business:

Years Acquainted:

Service Record

Branch of Service

Discharge Date & Rank

General Information

Have Any of Your Licenses to Practice Been Limited, Suspended or Revokes?

Have You Ever Been Convicted of a Felony?

If yes, Explain (Will not necessarily exclude you from consideration)

Who Referred You to American Medical, Inc.

In What Locations Do You Want to Work?

Are You Willing to Relocate?

Can you drive a Car?

Foreign Applicants

US Immigration Status:

CIS Status:

Do You Speak Fluent English?

Have You Ever Been in the USA?

If yes, on which Visa

Dates (From and To):

Do You Have the Right to Work in the USA?




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 on this application shall be grounds for dismissal. I authorize investigation if all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and 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 the foregoing, unless it is in writing and signed by an authorized company representative." Entering your name in the box below serves as your digital signature certifying that the facts contained in this application are true and complete to the best of your knowledge and that you have read and understand the authorization above.
	Name of Applicant*: (Required)
	Date:

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