Employment Application Form - Baldwin Bone & Joint PC

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MAIN (251) 625-2663 PHYSICAL THERAPY: (251) 625-3178

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Physicians & Staff
For Patients
For Physicians
Services
Physical Therapy
Locations
Careers
News
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MAIN (251) 625-2663
PT (251) 625-3178

Make An Appointment

Make a Payment

Submit Resume or Application

Upload your completed application or resume/CV as one of the following file types: DOC, DOCX, PDF

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EMPLOYMENT APPLICATION

Personal Information

Name *

Middle

Last

Today's Date:

Street Address *

Street Address: *

Email Address *

Phone Number *

Date Available: *

Desired Pay *

Desired Pay: *

Hour

Salary

Position Applied For: *

Employment Desired: *

Full-time

Part-time

Seasonal

Employment Eligibility

Are you legally eligible to work in the U.S.? *

Yes

Have you ever worked for this employer? *

Yes

Enter the start date: *

Enter the end date: *

Have you ever been convicted of a felony? *

Yes

If yes, please explain: *

Education

High School

Name of High School: *

City/State *

Graduate? *

Yes

Diploma: *

College:

Name of College:

City/State:

Graduate?

Yes

Degree:

Other

Institution Name:

City/State:

From:

To:

Degree/Certification:

Other:

Institution Name:

City/State:

From:

To:

Degree/Certification:

Previous Employment

Please explain any gaps in your employment history.

Employer 1

Company/Individual Name:

Email:

Phone:

Address:

Starting Pay:

Hour

Salary

Ending Pay:

Hour

Salary

Job Title:

Responsibilities:

From:

To:

Reason for leaving:

Employer 2

Company/Individual Name:

Email:

Phone:

Address:

Starting Pay:

Hour

Salary

Ending Pay:

Hour

Salary

Job Title:

Responsibilities:

From:

To:

Reason for leaving:

Employer 3

Company/Individual Name:

Email:

Phone:

Address:

Starting Pay:

Hour

Salary

Ending Pay:

Hour

Salary

Job Title:

Responsibilities:

From:

To:

Reason for leaving:

References

Professional Only

Reference 1

Full Name

Relationship

Company:

Title:

Email:

Phone:

Reference 2

Full Name

Relationship

Company:

Title:

Email:

Phone:

Reference 3

Full Name

Relationship

Company:

Title:

Email:

Phone:

Military Service

Are you a veteran? *

Yes

Branch:

Rank at discharge:

From:

To:

Type of discharge:

What type of education, training, and work experience, relevant to the job did you receive while in the military?

Miscellaneous

Can you perform all essential functions and duties of your job? *

Yes

If offered employment, can and will you provide documentation that you are legally authorized to work? *

Yes

If offered employment, can and will you provide documentation that you are legally authorized to work (may not be relevant)? *

Yes

Have you ever been dismissed from an employment position? *

Yes

Have you ever been asked to resign from an employment position? *

Yes

Have you ever been investigated for misconduct related to your employment? *

Yes

Have you ever had a professional certificate, credential, or license of any kind revoked or suspended? *

Yes

Have you ever surrendered a professional license of any kind before its expiration? *

Yes

Background Check Consult:

If asked, are you willing to consent to a background check? *

Yes

Disclaimer:

Applicant understands that BB&J is an Equal Opportunity Employer and that BB&J is committed to excellence through diversity. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, national origin, veteran status or genetic information. BB&J is committed to providing access, equal opportunity and reasonable accommodations for individuals with disabilities in employment, its services, programs, and activities.

In order to ensure this application is acceptable, please print or type with the application being fully completed in order for it to be considered. Please complete each section EVEN if you decide to attached a resume.

I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information in my application and/or interview may result in my employment being terminated.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Print Name of Applicant *

Signature of Applicant: *

Date:

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You may schedule an orthopaedic clinic appointment online, by calling our office at (251) 625-BONE (2663) or by faxing (251) 625-3198. Our physical therapy clinic phone number is (251) 625-31PT (3178).

For emergencies, we are available and on-call 24/7, including holidays. If you have an emergency, please call our office at (251) 625-2663.

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Personal Information

Employment Eligibility

Education

High School

College:

Other

Other:

Previous Employment

Employer 1

Employer 2

Employer 3

References

Reference 1

Reference 2

Reference 3

Military Service

Miscellaneous

Background Check Consult:

Disclaimer:

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