Physicians Surgery Center | Jackson, Tennessee

Personal Information

Name

Position(s) you're applying for

Social Security #

Email Address

Home Phone

Cell Phone

Address

Military Service

Have you ever served in the U. S. Armed Forces?

Yes No

What Branch?

Describe any training received relevant to the position for which you are applying

Education

High School

Name

Dates Attended

Did you graduate?

Yes No

Degree

Address

College

Name

Dates Attended

Did you graduate?

Yes No

Degree

Address

Other Schooling

Name

Dates Attended

Did you graduate?

Yes No

Degree

Address

Previous Employment

Previous Employment Please give an accurate, complete full-time and part-time employment record. Start with your present or most recent employer.

Company 1

Company

Phone

Address

Supervisor

Position

Starting Hourly Rate or Salary

Ending Hourly Rate or Salary

Primary Responsibilities

Dates at this job

Reason for leaving

We may contact this employer unless you indicate those you do not want us to

Please do not contact this employee

Reason

Company 2

Company

Phone

Address

Supervisor

Position

Starting Hourly Rate or Salary

Ending Hourly Rate or Salary

Primary Responsibilities

Dates at this job

Reason for leaving

We may contact this employer unless you indicate those you do not want us to

Please do not contact this employee

Reason

Company 3

Company

Phone

Address

Supervisor

Position

Starting Hourly Rate or Salary

Ending Hourly Rate or Salary

Primary Responsibilities

Dates at this job

Reason for leaving

We may contact this employer unless you indicate those you do not want us to

Please do not contact this employee

Reason

Additional Information

Describe any specialized training, apprenticeship, skills and extra-curricular activities.

List professional, trade, business or civic activities and offices held and awards, accomplishments, etc.

State any additional information you feel may be helpful to us in considering your application.

Applicant's Statement

Please read and understand this statement before signing your application:

The information I have provided in this Application for Employment is true, correct and complete. False, incomplete or misrepresented information of any kind, will be sufficient cause for my application to be rejected or, if discovered after I am employed, cause for immediate termination of my employment. This application for employment shall be considered active for a period of time not to exceed 45 days. After that date, unless otherwise notified, I understand that my status as an applicant will end. I may re-apply for employment in the future by completing a new application.

I authorize Physicians Surgery Center to contact and obtain information about me from previous employers, educational institutions and "references" I have provided, and any other party necessary to verify the accuracy of information I have disclosed in this application, a related employment resume or a personal interview. I authorize Physicians Surgery Center, to perform a background investigation on myself. I have disclosed any criminal convictions or any civil monetary penalties assessed against as previously asked in this application. To assist in the processing of my application, I waive all rights and claims I may otherwise have against the employer or its representatives, for seeking, and using information to evaluate my employment request and all other persons, corporations or organizations who provide information for this purpose.

I hereby understand and acknowledge that, this application is not an employment agreement, and unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

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