Employment Application

The Whole List Doc Employment Application

The Whole List Doc is an equal opportunity employer. The Whole List Doc. does not discriminate in employment with regard to race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service or any other characteristic protected by law.

PERSONAL INFORMATION

Incomplete information could disqualify you from further consideration. Please complete all fields.

Name

First

Last

Date of Birth

Phone

Position Applied for:

Your Email

Available Start Date

Desired Hourly Rate:

Please specify rate by numbers

Home Address

Address Line 1

City

State

Zip Code

Full Time or Part Time or Contract/PRN

Are you authorized to work and remain in the United States?

What document can you provide as proof of citizenship or legal status?

US Passport
Birth Certificate
Other

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

Have you ever been terminated from employment or asked to resign by an employer?

Have you ever been convicted of a felony?

Do you have a reliable form of transportation?

EDUCATION

Highest level of Education:

Year of Graduation:

Do you have any Professional Certifications / Licenses:

*Please do not put Driver's license as Professional License*

Attach Copy of Certification / Licensure / Diploma / Degree

Drag & Drop Files, Choose Files to Upload

PDF or Word document only.

Cover Letter

Drag & Drop Files, Choose Files to Upload

PDF or Word document only.

Resume

Drag & Drop Files, Choose Files to Upload

PDF or Word document only.

REFERENCES

Please list three professional references:

Name

First

Last

Relationship

Phone:

Name

First

Last

Relationship

Phone:

Name

First

Last

Relationship

Phone:

EMPLOYEMENT

Starting form last employment

Company Name 1

Phone:

Job Title

From:

What is/was your Pay Rate?

To:

Reason for Leaving?

May we contact your previous supervisor for a reference?

Company Name 2

Phone:

Job Title

From:

What was your Pay Rate?

To:

Reason for Leaving?

May we contact your previous supervisor for a reference?

Company Name 3

Phone:

Job Title

From:

What was your Pay Rate?

To:

Reason for Leaving?

May we contact your previous supervisor for a reference?

MEDICAL QUESTIONNAIRE

All staff members complete this section:

Do you have any medical condition requiring treatment?

Do you have any mental health condition requiring treatment or therapy?

Do you feel your medical or mental health condition will impact your ability to perform your work?

Do you think you may need any assistance to help you to do the job?

Please select what describes you the best.

	Never	Rarely	Sometimes	Agree	Often	Always
I am assertive, demanding, and decisive.	NeverI am assertive, demanding, and decisive. Never	RarelyI am assertive, demanding, and decisive. Rarely	SometimesI am assertive, demanding, and decisive. Sometimes	AgreeI am assertive, demanding, and decisive. Agree	OftenI am assertive, demanding, and decisive. Often	AlwaysI am assertive, demanding, and decisive. Always
I enjoy doing multiple tasks at once.	NeverI enjoy doing multiple tasks at once. Never	RarelyI enjoy doing multiple tasks at once. Rarely	SometimesI enjoy doing multiple tasks at once. Sometimes	AgreeI enjoy doing multiple tasks at once. Agree	OftenI enjoy doing multiple tasks at once. Often	AlwaysI enjoy doing multiple tasks at once. Always
I thrive in a challenge-based environment.	NeverI thrive in a challenge-based environment. Never	RarelyI thrive in a challenge-based environment. Rarely	SometimesI thrive in a challenge-based environment. Sometimes	AgreeI thrive in a challenge-based environment. Agree	OftenI thrive in a challenge-based environment. Often	AlwaysI thrive in a challenge-based environment. Always
I think about tasks above others or myself.	NeverI think about tasks above others or myself. Never	RarelyI think about tasks above others or myself. Rarely	SometimesI think about tasks above others or myself. Sometimes	AgreeI think about tasks above others or myself. Agree	OftenI think about tasks above others or myself. Often	AlwaysI think about tasks above others or myself. Always
I am motivated by accomplishment and authority.	NeverI am motivated by accomplishment and authority. Never	RarelyI am motivated by accomplishment and authority. Rarely	SometimesI am motivated by accomplishment and authority. Sometimes	AgreeI am motivated by accomplishment and authority. Agree	OftenI am motivated by accomplishment and authority. Often	AlwaysI am motivated by accomplishment and authority. Always
I enjoy influencing and inspiring people.	NeverI enjoy influencing and inspiring people. Never	RarelyI enjoy influencing and inspiring people. Rarely	SometimesI enjoy influencing and inspiring people. Sometimes	AgreeI enjoy influencing and inspiring people. Agree	OftenI enjoy influencing and inspiring people. Often	AlwaysI enjoy influencing and inspiring people. Always
I am optimistic about others.	NeverI am optimistic about others. Never	RarelyI am optimistic about others. Rarely	SometimesI am optimistic about others. Sometimes	AgreeI am optimistic about others. Agree	OftenI am optimistic about others. Often	AlwaysI am optimistic about others. Always
I tend to be the life of the party.	NeverI tend to be the life of the party. Never	RarelyI tend to be the life of the party. Rarely	SometimesI tend to be the life of the party. Sometimes	AgreeI tend to be the life of the party. Agree	OftenI tend to be the life of the party. Often	AlwaysI tend to be the life of the party. Always
I think about motivating people.	NeverI think about motivating people. Never	RarelyI think about motivating people. Rarely	SometimesI think about motivating people. Sometimes	AgreeI think about motivating people. Agree	OftenI think about motivating people. Often	AlwaysI think about motivating people. Always
I am motivated by recognition and approval.	NeverI am motivated by recognition and approval. Never	RarelyI am motivated by recognition and approval. Rarely	SometimesI am motivated by recognition and approval. Sometimes	AgreeI am motivated by recognition and approval. Agree	OftenI am motivated by recognition and approval. Often	AlwaysI am motivated by recognition and approval. Always
I thrive in consistent environments over changing ones.	NeverI thrive in consistent environments over changing ones. Never	RarelyI thrive in consistent environments over changing ones. Rarely	SometimesI thrive in consistent environments over changing ones. Sometimes	AgreeI thrive in consistent environments over changing ones. Agree	OftenI thrive in consistent environments over changing ones. Often	AlwaysI thrive in consistent environments over changing ones. Always
I prefer specifics over generalizations.	NeverI prefer specifics over generalizations. Never	RarelyI prefer specifics over generalizations. Rarely	SometimesI prefer specifics over generalizations. Sometimes	AgreeI prefer specifics over generalizations. Agree	OftenI prefer specifics over generalizations. Often	AlwaysI prefer specifics over generalizations. Always
I enjoy small groups of people.	NeverI enjoy small groups of people. Never	RarelyI enjoy small groups of people. Rarely	SometimesI enjoy small groups of people. Sometimes	AgreeI enjoy small groups of people. Agree	OftenI enjoy small groups of people. Often	AlwaysI enjoy small groups of people. Always
I prefer being a member of a team over leading the team.	NeverI prefer being a member of a team over leading the team. Never	RarelyI prefer being a member of a team over leading the team. Rarely	SometimesI prefer being a member of a team over leading the team. Sometimes	AgreeI prefer being a member of a team over leading the team. Agree	OftenI prefer being a member of a team over leading the team. Often	AlwaysI prefer being a member of a team over leading the team. Always
I am motivated by stability and support.	NeverI am motivated by stability and support. Never	RarelyI am motivated by stability and support. Rarely	SometimesI am motivated by stability and support. Sometimes	AgreeI am motivated by stability and support. Agree	OftenI am motivated by stability and support. Often	AlwaysI am motivated by stability and support. Always
I typically do not take big risks.	NeverI typically do not take big risks. Never	RarelyI typically do not take big risks. Rarely	SometimesI typically do not take big risks. Sometimes	AgreeI typically do not take big risks. Agree	OftenI typically do not take big risks. Often	AlwaysI typically do not take big risks. Always
I love tasks, order and details.	NeverI love tasks, order and details. Never	RarelyI love tasks, order and details. Rarely	SometimesI love tasks, order and details. Sometimes	AgreeI love tasks, order and details. Agree	OftenI love tasks, order and details. Often	AlwaysI love tasks, order and details. Always
I am right most of the time.	NeverI am right most of the time. Never	RarelyI am right most of the time. Rarely	SometimesI am right most of the time. Sometimes	AgreeI am right most of the time. Agree	OftenI am right most of the time. Often	AlwaysI am right most of the time. Always
I comply with clearly defined rules.	NeverI comply with clearly defined rules. Never	RarelyI comply with clearly defined rules. Rarely	SometimesI comply with clearly defined rules. Sometimes	AgreeI comply with clearly defined rules. Agree	OftenI comply with clearly defined rules. Often	AlwaysI comply with clearly defined rules. Always
I am motivated by quality and correctness.	NeverI am motivated by quality and correctness. Never	RarelyI am motivated by quality and correctness. Rarely	SometimesI am motivated by quality and correctness. Sometimes	AgreeI am motivated by quality and correctness. Agree	OftenI am motivated by quality and correctness. Often	AlwaysI am motivated by quality and correctness. Always

**I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for The Whole List Doc to hire me. If I am hired, I understand that either The Whole List Doc 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 Whole List Doc has the authority to make any assurance to the contrary.

I attest with my signature below that I have given to The Whole List Doc. true and complete information on this application. No requested information has been concealed. I authorize The Whole List Doc. 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 the denial of employment or immediate dismissal.
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above**.

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Clear Signature

Today's Date

Employment Application

The Whole List Doc Employment Application

PERSONAL INFORMATION

EDUCATION

REFERENCES

EMPLOYEMENT

MEDICAL QUESTIONNAIRE

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