* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):

Yes   No

* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):

Yes   No

* Have you earned a high school diploma or equivalent?:

Yes   No

* Have you applied to this company before or worked for this company under your current name or under a different name or email address?:

Yes   No

If so, please list the name and/or email address used in prior application(s).:

* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:

Yes   No

If no, please explain:

* Have you ever been convicted of a felony?:

Yes   No

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location	From	To	Did you Graduate?	Degree Received	Subjects Studied/Major
			Yes   No   In Progress
			Yes   No   In Progress
			Yes   No   In Progress

Give your employment record starting with your current or most recent employer and going back 5 years.

Applicants must fully complete the Employment History section on this application.

Please note, some positions may require a resume in addition to a completed application. Refer to the job posting for details.

Month/Year Employed	Employer Name	Employer City/State
From: * To: *	*	*
Job Title
*
Reason for Leaving	Salary/Hourly Rate
*	Start: * End: *

Month/Year Employed	Employer Name	Employer City/State
From: To:
Job Title
Reason for Leaving	Salary/Hourly Rate
	Start: End:

Month/Year Employed	Employer Name	Employer City/State
From: To:
Job Title
Reason for Leaving	Salary/Hourly Rate
	Start: End:

* Desired Hourly Rate/Salary:

* Would you be able to attend up to 8 days of mandatory new employee orientation (week 1 Monday-Friday 8am-5pm) along with 4-6 flexible in-clinic training shifts?:

Yes   No

* Where did you hear about this position? (example: Dept of Labor, Craigslist, Indeed, etc).:

* Were you referred by a Primary Health Medical Group employee?:

Yes   No

If you were referred by an employee, please list that employee's name here.:

* We require all staff to have a flu shot.  We will bill your insurance or provide to at no cost if uninsured.  Would you be willing to receive this vaccination?:

Yes   No

* Primary Health Medical Group is a tobacco free workplace. We do not allow any tobacco use on the premises, including vaping, smoking and chewing. Do you agree to abide by this policy?:

Yes   No

* We are a drug-free workplace.  If offered the job, you would need to submit to a pre-employment drug screen.  Would you be willing to submit to the pre-employment drug screen if a job is offered?:

Yes   No

* Criminal background checks are conducted on all new hires.  Would you be willing to submit to a criminal background check if offered a position?:

Yes   No

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

* Signature (type name):

* Date: