If yes, when?
Do you have any friends or relatives working for the Company?
If yes, state name(s) and relationship
If hired, would you have a reliable means of transportation to and from work?
Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.)
Do you have the legal right to work and be employed in the United States (Proof of identity and legal authority to work in the U.S. is a condition of employment.)
Are you able to perform the functions of the job for which you are applying with or without reasonable accommodation?
If no, describe the functions that you cannot perform
Have you ever been convicted of a felony which has not been judicially ordered sealed, expunged, or statutorily eradicated
If yes, state nature of the felony or felonies, when and where convicted and disposition of the case
(Note: No applicant will be denied employment solely on the grounds of conviction of a felony offense. The nature of the offense, the date of the offense, the surrounding circumstances, the relevance of the offense to the position(s) applied for and any other relevant factor are considered.)
Are you currently employed?
If so, may we contact your current employer?
If no, explain why not.
Name and Address:
No. of years Completed
Did you Graduate?
Degree or Diploma
GPA (A = 4.0)
College/University
Name and Address:
No. of years Completed
Did you Graduate?
Degree or Diploma
GPA (A = 4.0)
Vocational/
Business
Name and Address:
No. of years Completed
Did you Graduate?
Degree or Diploma
GPA (A = 4.0)
Other
Name and Address:
No. of years Completed
Did you Graduate?
Degree or Diploma
GPA(A = 4.0)
Hobbies, Special Interests, Extra Curricular Activites
What are your hobbies, special interests, and extracurricular activities? (Please omit those which indicate your race, color, religion, sexual orientation, marital status, national origin, ancestry, age, disability or any other basis protected by law.)
Please Read Carefully, Initial Each Paragraph and Sign Below.
I hereby certify that the answers given by me on this application are true and correct to the best of my knowledge, and that I have not withheld any information that might adversely affect my chances for employment. I understand that any misstatement or omission of fact on this application or any documents used to obtain employment may result in rejection of this application or immediate discharge if I am employed, regardless of the time elapsed before discovery of the misstatement or omission. I further certify that I, the applicant, have personally completed this application.
Initials
I hereby authorize Southern California Orthopedic Institute Medical Group (“SCOI”) to investigate my references, prior employers, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed, all prior employers, and all educational institutions attended, to disclose to SCOI any and all letters, reports and other information related to my records, including but not limited to my performance reviews and evaluations, discipline, commendations, awards, and all other employment information, without giving me prior notice of such disclosure. By providing this page of the application, or a copy hereof, to the references, prior employers and educational institutions attended, I release them, to the fullest extent permitted by law, from any and all claims, demands, fees and liabilities for providing SCOI with all information, and I release SCOI, and its agents, employees, clients, or representatives, to the fullest extent permitted by law, from any and all claims, demands, fees and liabilities that may result from any use or disclosure of such information by SCOI, or any of its agents, employees, clients, or representatives.
Initials
I understand that any employment with SCOI is at the mutual consent of me and SCOI. Accordingly, either I or SCOI may terminate my employment at any time, with or without cause, and with or without notice. I understand that except for SCOI =s Chief Executive Officer, no employee, representative or agent of SCOI has authority to modify the at-will nature of my employment. Any modification of the at-will nature of my employment, or any employment agreement for a specified period of time with SCOI, must be set forth in a written agreement signed and dated by me, on the one hand, and SCOI =s Chief Executive Officer, on the other hand. Moreover, nothing conveyed to me, either during any pre-employment interview, or during my employment, if hired, is intended to create an employment contract between me and SCOI or to alter the at-will nature of my employment with SCOI. In addition, I understand that if hired by SCOI, this statement shall constitute a final and fully binding integrated agreement with respect to the at-will nature of my employment relationship and that there are no oral or written agreements of any kind contrary to the foregoing.
Initials
I hereby agree to submit to binding arbitration all disputes and claims I may have arising out of or related to my applying for employment with SCOI, in accordance with the provisions of the arbitration of disputes policy set forth in SCOI =s Employee Handbook. If I am hired by SCOI, I further agree that all disputes and claims I may have which arise out of or are related to my employment with SCOI, whether during or after that employment, that cannot be resolved by informal internal resolution, will be submitted to binding arbitration to the fullest extent permitted by law, in accordance with the provisions of the arbitration of disputes policy set forth in SCOI =s Employee Handbook. I have been given a copy of the arbitration of disputes policy set forth in SCOI =s Employee Handbook. I have read that policy and I knowingly, intentionally, and voluntarily agree to the provisions of that policy in all respects.
Initials
I further understand and agree that as a condition to being employed by SCOI, I will be required to agree to conduct myself in accordance with SCOI =s personnel practices and policies as set forth in the Employee Handbook, a copy of which I will be provided and will review prior to accepting employment with SCOI.
Initials
Today's Date
Applicant's Full Name (in lieu of signature)
