Application Form

An Equal Opportunity Employer

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

  • Are you seeking: * Required
  • Are you 18 years of age or older? * Required
  • If hired, can you furnish proof that you are eligible to work in the US? * Required
  • Have you ever applied to New West Physicians before? * Required
  • Were you ever employed at New West Physicians? * Required
  • Are you currently a tobacco user? * Required
  • Are you now or do you expect to be engaged in any other business or employment? * Required
  • Do you have a valid driver's license? * Required
  • Have you had your driver’s license suspended or revoked in the last 3 years?
  • 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.

  • Are you presently employed?
  • If yes, can we contact your present employer?
  • Have you ever been fired from a job or asked to resign?
  • 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.

  • AFFIDAVIT

    PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

    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.