We do not discriminate on the basis of race, color, religion, national origin, sex, age, or disability. It is our intention that all qualified applicants are given equal opportunity and that selection decisions be based on job-related factors. New West, in an effort to promote a healthy lifestyle and disease prevention for our patients and employees, has adopted a tobacco-free workplace
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Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. In reading and answering the following questions, be aware that none of the intended to imply illegal preferences or discrimination based upon non-job-related information
Job Applied for *
Job Site Location *
Today's Date select date *
Are you seeking: Full-time Part-time Temporary employment *
When could your start work? select date *
Last Name *
First Name *
Middle Name *
Telephone Number *
Present Street Address *
State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming *
ZIP code *
Are you 18 years of age or older? Yes No *
If hired, can you furnish proof that you are eligible to work in the US? Yes No *
Last Four Digits of Your Social Security Number
How did you hear about this position?*
Have you ever applied to New West Physicians before? Yes No *
If yes, when? select date
Were you ever employed at New West Physicians? Yes No *
If Yes, When did you start? select startdate
Until? select end date
Do any of your relatives currently work for New West? If yes, who?
Are you currently a tobacco user? Yes No *
Are you now or do you expect to be engaged in any other business or employment? Yes No *
If yes, please explain:
Name of School: *
City, State, ZIP
Years completed: 012345 *
Name of School:
Years completed: 012345
What skills or additional training do you have that are related to the job for which you are applying?*
What machines or equipment can you operate that are related to the job for which you are applying?*
Do you have a valid driver's license? Yes No
Driver's License Number
Class of License
Have you had your driver’s license suspended or revoked in the last 3 years? Yes No
If yes, give more details:
List professional, trade, business or civic activities and offices held.
List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. Self-employed, give firm name and supply business references.NOTE: A job offer may be contingent upon acceptable references from current and former employers.
Attach Your Resume
Name of Employer:
City, State, ZIP:
Employment Start select start date
Employment End select end date
Reason for leaving:
Reason for leaving:
Are you presently employed? Yes No *
If yes, can we contact your present employer? Yes No
Have you ever been fired from a job or asked to resign? Yes No *
I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment drug screen.
I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me form further consideration for employment and may result in my dismissal if discovered at a later date.
I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.
I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYEMENT NOR GUARANTEE EMPLOYEMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE.
I HAVE READ, UNDERSTAND, AND BY MY SIGNATURE CONSENT TO THESE STATEMENTS.
This application for employment will remain active for a limited time.
Thank you for filling out the Application for Employment. We have recieved your application and will contact you if we would like to speak with you further about this position.
New West Physicians