Are you eligible to work in the U.S.?   Yes No

Are you at least 18 years or older?   Yes No
If no, you may be required to provide authorization to work.

During the last ten years, have you ever been convicted of a crime other than a minor traffic violation? A conviction will not necessarily automatically disqualify you for employment. Rather, such factors as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.  
Yes No
If yes, please provide details (dates and location for all convictions)

Have you ever been terminated from employment or asked to resign by an employer?   Yes No

Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodation?   Yes No

EMPLOYMENT DESIRED

Date you can start    Hourly Rate/Salary desired

Position Desired

Are you currently employed?   Yes No   
If so, may we contact your current employer?   Yes No

REFERRAL SOURCE

How did you hear about us?   Walk in Advertisement Other
If other please explain

Have you worked for this company before?   Yes No
If yes, please explain

Do you know anyone who works for our company?   Yes No
If yes, who?

If you have any special skills, experience and/or training that would enhance your ability to perform the position you are applying for, please explain them here

EMPLOYMENT HISTORY Include your last five years of employment history, starting with the most recent.

REFERENCES Give the names of 3 persons not related to you, whom you have known for at least 3 years.

Please read carefully before signing

Midwest Internal Medicine is an equal opportunity employer. Midwest Internal Medicine does not discriminate in employment on account of race, color, religion, national origin, citizenship status, ancestry, age, sex, sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service.

Midwest Internal Medicine is a drug free workplace. I understand that I may be required to give blood, urine, or saliva for a drug test as a condition of my employment if hired.

I understand that the completion of this application nor any other part of my consideration for employment establishes any obligation to Midwest Internal Medicine to hire me. If I am hired, I understand that either Midwest Internal Medicine or I can terminate my employment at any time for any reason, with or without cause and without prior notice. I understand that no representative of Midwest Internal Medicine has the authority to make any assurance to the contrary.

By checking this box and entering my name and date below, I attest that I have given Midwest Internal Medicine true and complete information on this application. No requested information has been concealed. I authorize Midwest Internal Medicine to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for denial of employment or immediate dismissal.

Date    Name