Employment Application

Waco Family Medicine (hereafter referred to as WFM) does not discriminate in hiring or employment on the basis of race, color, age, sex, religion, creed, national origin, ancestry, veterans or disability. No question on this application is intended to secure information to be used for such discrimination. WFM will reasonably accommodate all applicants and employees with disabilities if WFM is informed of such disability.

Application Date*

Last Name*

First Name*

Middle Name

Street Address*

City*

State*

Zip Code*

Telephone*

Personal Email Address*

Sex*

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What job are you applying for?*

Are you seeking full-time or part-time employment?

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How did you first find out about this job

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If "Other," please explain

Are you willing to work overtime?

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Are you willing to work on Saturdays, if needed?

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About You

Are you currently 18 years or older?*

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Are you a current employee at Waco Family Medicine?*

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Have you previously applied for employment at Waco Family Medicine?

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When did you last submit an application?

Have you previously been employed at Waco Family Medicine?

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Please provide the date when your previous employment at WFM ended (if unsure, choose the 1st day of your last month of employment)

Why did you stop working at WFM?

Are you employed now?

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May we contact your current employer?

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List any friends or relatives currently working at WFM

WFM Employee Referral (optional)

If one or more current WFM employees referred you directly to this job opening, please list their names here

Language

What languages do you speak and write fluently?

Have you been convicted of a felony?*

(Such a conviction is not an automatic bar to employment. Any information supplied regarding the circumstances, rehabilitation and age at the time will be considered. You may include additional information which you want considered.)

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If yes, please provide date and description/explanation of conviction

Have you used tobacco or e-cigarette products in the last 6 months?*

Waco Family Medicine is a tobacco-free workplace and does not hire tobacco/e-cigarette users.

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Work Authorization

Are you already authorized to work in the U.S.?

(Note that a false answer may be considered fraud and later could negatively impact applications for citizenship and work authorization. Documentation of work authorization or citizenship will be required prior to the start of employment.)

Education and Skills

Do you have a GED or High School Diploma?

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Education: Attendance Dates, Degree(s) or Hours

Please list all high schools, colleges/universities attended, dates of attendance, and hours or degrees earned

List any certifications or awards received

Previous Employment and References

Current or Most Recent Employer*

Current/Most Recent Employer: Dates of Employment

Current/Most Recent Employer: Contact Info

Include contact name, email and/or phone number

Current/Most Recent Employer: Position and Duties

Current/Most Recent Employer: Reason for Leaving (if applicable)

Former Employer #1*

Former Employer #1: Dates of Employment

Former Employer #1: Contact Info

Include contact name, email and/or phone number

Former Employer #1: Position and Duties

Former Employer #1: Reason for Leaving

Former Employer #2*

Former Employer #2: Dates of Employment

Former Employer #2: Contact Info

Include contact name, email and/or phone number

Former Employer #2: Position and Duties

Former Employer #2: Reason for Leaving

Reference #1*

Please provide the name and contact of information of a personal or professional reference who is not related to you. Please also include a description of this person' relationship to you (e.g., former supervisor).

Reference #2*

Reference #3*

Additional Information

Please provide any additional information you believe would help us review your application.

Additional Information

Upload resume, if available

Drag and drop files here or

Certification

NOTE: PLEASE CAREFULLY READ THE STATEMENTS BELOW. AFTER YOU HAVE READ THE STATEMENTS, PLEASE SIGN AND DATE IN THE SPACE PROVIDED BELOW. “I certify that the facts contained in this application and in any resume or other material provided to WFM and in any oral statements by me are true and complete to the best of my knowledge. I understand that, if employed, omissions, incomplete statements, or false statements on this application or other materials supplied to WFM or in oral statements by me in the hiring process shall be grounds for dismissal. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN. THIS INVESTIGATION MAY CHECK CRIMINAL, CREDIT AND MOTOR VEHICLE RECORDS. I agree to fully cooperate in this investigation, including personally requesting any information as necessary. Further, I authorize the employers and references listed above to give WFM any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to WFM.” I UNDERSTAND AND AGREE THAT, IF HIRED: 1. My employment is for no definite period but may be terminated by WFM at any time without any prior notice and without cause. 2. No officer or employee of WFM can guarantee me any specific salary or benefit or employment for any period of time, except by written agreement between me and WFM signed by the Secretary/Treasurer of WFM. 3. I will comply with all rules and regulations of WFM including the Drug-free Workplace, Confidentiality and Tobacco-Free Workforce Policies. Failure to comply will result in employment and or financial penalties as deemed by WFM. I understand that WFM’s rules, regulations and policies are not a contract and may be changed or waived by WFM at any time.

I agree*

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Please type your name below to electronically sign this application.*

After you have saved the application, you will be provided with a form to complete for Equal Opportunity Employment data collection. Thank you for showing interest at Waco Family Medicine!

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