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

Perosonal Info

Phone *

Date of Birth *

Position Applied for: *

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? *

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? *

If "Yes" please provide details:

Have you ever been convicted of a felony? *

If "Yes" please provide details:

EDUCATION

Highest level of Education: *

Year of Graduation: *

Do you have any Certifications / Licenses: *

Attach Copy of Certification / Licensure / Diploma / Degree *

Click or drag a file to this area to upload.

REFERENCES

Please list three professional references:

Name *

First

Last

Relationship *

Phone *

Email *

Name *

First

Last

Relationship *

Phone *

Email *

Name *

First

Last

Relationship *

Phone *

Email *

EMPLOYEMENT

Starting form last employment

Company Name 1 *

Phone *

Job Title *

Info Needed 1

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

Info Needed 2

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

Info Needed 3

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? *

If your answer is yes, please provide further details of the condition, treatment, prescription and dates: *

Cover Letter

Click or drag a file to this area to upload.

Resume *

Click or drag a file to this area to upload.

Signature *

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.

Today's Date *

Employment Application

The Whole List Doc Employment Application

PERSONAL INFORMATION

EDUCATION

REFERENCES

EMPLOYEMENT

MEDICAL QUESTIONNAIRE

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