Sending Medical Form

Employment Application Form

EQUAL EMPLOYMENT OPPORTUNITY

All employees of Spine Dynamics PC are selected on the basis of their ability to fulfill established specifications for the job. General criteria include education, experience, interpersonal skills, physical ability, and willingness and compatibility to work in the specific environment. No person is discriminated against in regard to race, color, creed, religion, gender, age, citizenship, national origin, marital status, sexual orientation, disability, or any other status or characteristic protected under applicable local, state or federal laws.

EDUCATION AND TRAINING
EMPLOYMENT RECORD (include all employment for the past 5 years)


EDUCATION AND TRAINING

Please list 3 reference names, telephone numbers, and years known. Do not include relatives or employers.

OTHER

I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employments decision and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment.