WELCOME

Thank you for your interest in our position. Please fill out the application below and it will submit securely to our office. We look forward to hearing from you.

If hired, would you have transportation to/from work?
Are you over the age of 18?
If hired, would you be able to present evidence of your USA citizenship or proof of your legal right to work in USA?
Do you have any past experience in the chiropractic, medical, or dental field?

PAST EMPLOYMENT

List in chronological order beginning with the most recent, if included in resume, please complete the details.

May we contact?

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SECOND MOST RECENT POSITION.

May we contact?
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REFERENCES

List below three persons who have knowledge of your work performance within the last four years. Please include a minimum of 2 professional references.

BUSINESS REFERENCES

PERSONAL REFERENCES

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EDUCATION

List in chronological order beginning with the most recent, if included in resume, please be sure to include GPA.

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PERSONAL INFORMATION

Do you like to work with

Are you applying for

What days and hours are you available for work?
Do you have any hour limitations for working?

Are you able to perform the essential functions of the job for which you are applying, either with / without reasonable accommodation?

Yes or No
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CAREER AIMS/PERSONALITY ASSESSMENT

Do you speak, write or understand any foreign languages?
Please rate yourself on a scale of 1-10, 10 being the highest (you can use the same number multiple times)
Willingness
Flexibility
Responsibility
Office Skills
Self-Esteem
Dependability
Assertiveness
Enthusiasm
Multi-Tasking
Attention To Details
Competitiveness
Confrontation Skills
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PLEASE READ AND SIGN BELOW

I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true & correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure can be grounds for rejection of application or, if I am employed by this company, terms for my immediate expulsion from the company.

I permit the company to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers & all other persons, corporations, partnerships & associations from any & all claims, demands or liabilities arising out of or in any way related to such examination or revelation.