Apply to Join Pioneer Medical Group

Please complete this form and upload requested documents.

APPLICANT INFORMATION

Non-Clinical Position Applying For

File upload

Please Upload CV

Drop your files here

Last Name

Middle Initial

First Name

Street Address

Apartment/Unit #

City

State

Zip / Postal Code

Primary Phone

Date Available

mm/dd/yyyy

Desired Salary

Social Security Number

Are you a citizen of the United States?

Yes

Have you ever worked for this Company?

Yes

Have you ever been convicted of a felony?

Yes

EDUCATION

College

College Address

College From Date

mm/dd/yyyy

College To Date

mm/dd/yyyy

Did you graduate?

Yes

Diploma:

Other Education

Other Address

Other From Date

mm/dd/yyyy

Other To Date

mm/dd/yyyy

Did you graduate?

Yes

Degree

PREVIOUS EMPLOYMENT

Company

Address of Previous Employment

Phone

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From Date

mm/dd/yyyy

To Date

mm/dd/yyyy

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

Voluntary EEO Information

Completion of this data is voluntary and will not affect your opportunity for employment, or terms or conditions of employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the HR department.

Ethnic Origin

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin regardless of race. White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa. American Indian or Alaskan Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including for example Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.

Background Notification and Authorization

Notification The position for which I am being considered requires me to consent to a criminal background check as a condition of employment. This check includes the following: Criminal history reference searches for felony and misdemeanor convictions at the county and federal levels of every jurisdiction where I currently reside or where I have resided during the past 7 years, references, and professional license verification. Authorization I hereby authorize Pioneer Medical Group to conduct the criminal background check described above. In connection with this, I also authorize the use of law enforcement agencies and/or private background check organizations to assist Pioneer Medical Group in collecting this information. SterlingONE has been secured as a third party vendor to assist Pioneer Medical Group in collecting and verifying information. I also am aware that records of arrests on pending charges and/or convictions are not an absolute bar to employment.

Background Form - Signature

Date of Birth:

mm/dd/yyyy

Gender:

Female

Male

Driver’s License #

State of Driver’s License

Have you ever been convicted of a criminal *offense or have any pending criminal* charges against you?

*This refers only to felonies and misdemeanors; you do not need to include non-criminal traffic violations or municipal ordinance violations.

Yes

To the best of my knowledge, the information provided in this Notice and Authorization and any attachments thereto is true and complete. I understand that any falsification or omission of information may disqualify me for this position and/or may serve as grounds for the severance of my employment with Pioneer Medical Group. By signing below I hereby provide my authorization to Pioneer Medical Group to conduct a criminal background check. In addition to those rights, I understand that I have a right to appeal an adverse employment decision made by Pioneer Medical Group based on my background check information within three business days of receipt of such notice and that a determination on my appeal will be made in seven working days from Pioneer Medical Group’s receipt of such appeal.

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature

Today's Date

mm/dd/yyyy

Pioneer Medical Group is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status.

Once you leave this page, you won't be able to edit the information you entered.

Send me a copy of my responses

Report Abuse