Employment Application Application for Employment Step 1 of 6 16% Date MM slash DD slash YYYY Your Personal InformationYour Name(Required) First Last Date of Birth MM slash DD slash YYYY Social Security #(Required) Driver's License # Cell Phone Number Home Phone Number Your Email Address Enter Email Confirm Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Position Desired Date Available to Start Desired Salary Type of EmplymentChoose an answerFull-TimePart-TimeContractor/ 1099Are You Presently Employed?Choose an answerYesNoMay We Contact Your Present Employer?Choose an answerYesNo EducationElementary School City Years Attended Did you graduate?YesNoHigh School City Years Attended Did you graduate?YesNoCollege City Years Attended Degree Conferred Post Graduate City Years Attended Did you garduate?YesNoCertification, Training, or Subject of Special Study or Research Professional Licensing - Please include license # and attach a copy of the certificate. Did you serve in the military?Choose an answerYesNoBranch of Service Type of Discharge Date of Discharge Rank at Discharge Are You Legally Entitled to Work in the United States?Jet Medical Center will require verification of employment eligibility as required by law including completion of an I-9 form.Choose an answerYesNo Work ExperienceYour Previous Employer - CurrentPlease list your previous employers, the dates you worked and the position you heldName of EmployerDatesPositionPhoneCity & State Add RemoveTell Us More About Your Previous EmplyerStart DateEnd DateStarting SalaryFinal SalaryJob Title Add RemoveWere you fired?Choose an answerYesNoPlease explain why you want to change jobs. Your Previous Employer 2Please list your previous employers, the dates you worked and the position you heldName of EmployerDatesPositionPhoneCity & State Add RemoveTell Us More About Your Previous Employer 2Start DateEnd DateStarting SalaryFinal SalaryJob Title Add RemoveWere you fired?Choose an answerYesNoPlease explain why you wanted to change jobs. Your Previous Employer 3Please list your previous employers, the dates you worked and the position you heldName of EmployerDatesPositionPhoneCity & State Add RemoveWere you fired?Choose an answerYesNoPlease explain why you wanted to change jobs. Your Previous Employer 4Please list your previous employers, the dates you worked and the position you heldName of EmployerDatesPositionPhoneCity & State Add RemoveTell Us More About Your Previous Employer 4Start DateEnd DateStarting SalaryFinal SalaryJob Title Add RemoveWere you fired?Choose an answerYesNoPlease explain why you wanted to change jobs. ReferencesReference #1NameTitleAddresssYears KnownPhone # Add RemoveReference #2NameTitleAddresssYears KnownPhone # Add RemoveReference #3NameTitleAddresssYears KnownPhone # Add RemoveUpload Your ResumeUpload your resume in .pdf, .doc or .docx formatAccepted file types: pdf, doc, docx, Max. file size: 25 MB.Upload Supporting Documents - Certifications, cover letter, etc.Upload your file in .pdf, .doc or .docx formatAccepted file types: pdf, doc, docx, Max. file size: 25 MB. Certification of Essential Job FunctionsI have been advised of the essential job functions of the position for which I am applyingChoose an answerYesNoThere is nothing that would prevent me from performing the essential duties of the position for which I am applying.Choose an answerYesNoI believe that I cannot or will not be able to perform the essential duties of the position for which I am applying.Choose an answerYesNoHave you ever been convicted of a felony?Choose an answerYesNo Certification & AcknowledgmentInquiries may be made with my previous employers or others who may have knowledge of me, and schools or colleges. I authorize any such person or agency to give you any and all information concerning my previous education and employment, including but not limited to, an assessment of my job performance, ability and fitness and/or any other information they may have, personal or otherwise, and release all parties from any and all liability, claims, or damages that may directly or indirectly result from furnishing same.(Required)Choose an answerAgreeDo Not AgreePrior to my beginning work or during my employment, Jet Medical Center reserves the right to conduct a criminal background check for employment purposes. I understand that a prior criminal conviction will not necessarily make me ineligible for employment. I hereby consent to a criminal background check and authorize the release of the report and any other information to the company. I hereby release the company, its divisions, affiliates, and associates, and anyone acting on their behalf from any and all claims or liabilities of any nature arising from or related to the preparation of the information contained in the criminal background reports, and the disclosure of such information for employment purposes. I further understand that I will be responsible to repay the cost ofmy background screen (through payroll deductions up to $125.00) should I leave Jet Medical Center during my first 90 days of employment.(Required)Choose an answerAgreeDisagreePrior to my beginning work or during my employment, Jet Medical Center reserves the right to obtain consumer reports as part of Jet Medical Center’s evaluation of my job application/employment. The reports may include my driving record, an assessment of my insurability under Jet Medical Center’s insurance coverages or consumer reports. I hereby release the company, its divisions, affiliates, 6 and associates, and anyone acting on their behalf from any and all claims or liabilities of any nature arising from or related to the preparation of the information contained in the consumer reports, and driving records about me from time to time, as it deems appropriate, to evaluate my insurability or for other permissible purposes and the disclosure of such information for employment purposes.(Required)Choose an answerAgreeDisagreeI understand that as a condition of my employment, I must take and pass a pre or post employment urine and/or blood test at authorized threshold levels for any and all of the drugs or alcohol listed by Jet Medical Center's Drug Free Workplace Policy. I further understand that I will be responsible to repay the cost of my drug screen (through payroll deduction up to $55.00) should I leave or be terminated from Jet Medical Center during my first 90 days of employment.(Required)Choose an answerAgreeDisagreeI further understand, subject to confidentiality constraints and rights of appeal granted by State and Federal law, if the results of my pre or post employment drug and/or alcohol tests are POSITIVE (indicating substance abuse) and are received by Jet Medical Center prior to or during your employment with Jet Medical Center, notwithstanding any other disciplinary provisions contained in the Jet Medical Center Drug-Free Workplace Policy statement, I will be terminated for cause and Jet Medical Center may seek to deny any employment benefits I might attempt to obtain.(Required)Choose an answerAgreeDisagreePrior to beginning work with Jet Medical Center’s I will be required to sign a Non-Discrimination/Non-Retaliation Policy Agreement.(Required)Choose an answerAgreeDisagreePrior to beginning work with Jet Medical Center’s I will be required to sign a Confidentiality/Trade Secrets and Non- Solicitation Agreement.(Required)Choose an answerAgreeDisagreeI represent and warrant to Jet Medical Center that I am under no contractual or other restriction or obligation which would prevent me in any way from working with Jet Medical Center’s including but not limited to, a covenant not-to-compete, confidentiality agreement, and/or trade secret agreement. If I believe that I am presently under such contractual obligation, I will provide a copy of such agreement to Jet Medical Center(Required)Choose an answerAgreeDisagreeI also understand and agree that no representative of Jet Medical Center 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 approved by Parveen S. Vahora, M.D., President of Jet Medical Center(Required)Choose an answerAgreeDisagreeIf employed, I understand and agree that my employment is at-will and may be terminated with or without cause or notice at my option or at the option of Jet Medical Center.(Required)Choose an answerAgreeDisagreeI understand that any misrepresentation, falsification or omission of this application shall be sufficient reason for refusal or dismissal of my employment. I hereby authorize investigation of all matters contained in this application and agree that if the results of such investigation are not satisfactory, any offer of employment made by Jet Medical Center or any subsidiary hereinafter referred to as Jet Medical Center may be withdrawn, or my employment with Jet Medical Center may be terminated immediately.(Required)Choose an answerAgreeDisagreeYour Signature Today's Date MM slash DD slash YYYY
