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Doctors Home Visits is an Equal Opportunity Employer. We are hiring visiting physicians, physician assistants and nurse practitioners. After completing this application for employment, please attach your resumé at the bottom.

* Required

PERSONAL INFORMATION

Applicant Name: *

Phone: *    Social Security No. *

Address: *

Building or Apartment #:    City: *    State: *    Zip: *

How long have you lived here? *    Date of Birth: *

E-mail Address:

 

POSITION APPLYING FOR

Position applying for: *

Salary desired:    How many hours can you work weekly? *

Can you work nights? *     Yes     No

Employment desired: *     Full-Time Only     Part-Time Only     Full- or Part-Time

Days/Hours available to work:

Days Hours   Days Hours
Any Any   Thur
Mon   Fri
Tue   Sat
Wed   Sun

When can you start? *

 

LICENSE/REGISTRATION/CERTIFICATION

Please enter your certification information here:

Specialty:

 

EDUCATION
Name of School Location (Complete mailing address) Years Completed Major & Degree
High School
High School
College
College
Business/Trade School
Business/Trade School
Professional School
Professional School

 

Have you ever been convicted of a crime? *     No     Yes

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.


TRANSPORTATION

Do you have a driver's license? *     Yes     No

What is your means of transportation to work? *

Driver's license number:    State of issue:

Operator     Commercial     Chauffeur      Expiration Date:

Have you had any accidents during the past 3 years?     No     Yes    

Have you had any moving violations during the past 3 years?     No     Yes    

 

REFERENCES

Please list two references other than relatives or previous employers.

1. *

   

2. *

 
Name:   Name:
Position:   Position:
Company:   Company:
Address:   Address:
Phone:   Phone:

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

MILITARY

Have you ever been in the Armed Forces? *     Yes     No

Are you now a member of the National Guard? *     Yes     No

Specialty:

Date Entered:    Discharge Date:

 

WORK EXPERIENCE

Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name.

1.

Name of Employer:

Address:

City:    State:    Zip:    Phone:

Name of last supervisor:

Employment dates:    From    To

Pay or salary:    Start    Final

Reason for leaving (be specific):

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Add another employer

 

May we contact your present employer? *     Yes     No

Did you complete this application yourself? *     Yes     No

      If not, who did?

 

WAIVER – PLEASE READ CAREFULLY

In exchange for the consideration of my job application by AMERICAN VISTING DOCTORS hereinafter called “the Company”, I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of the Company or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President / Vice President of the Company. Both the undersigned and Doctors Home Visits may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.

I also understand that (1) the Company has a drug and alcohol policy that provides for pre employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I understand that, in connection with the routine processing of my employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

 

HIPPA CONFIDENTIALITY AGREEMENT

Employees, contractors and partners of the practice will have access to confidential information, both written and oral, in the course of their employment and job responsibilities. It is imperative that this information is not disclosed to any unauthorized individuals to maintain the integrity of the patient information.

An unauthorized individual would be any person that is not currently an employee of the practice. Any other disclosures may only occur at the direction of the Privacy Office or by patient authorization.

I have read and understand the practice’s policies with regards to privacy and security of personal health information. I agree to maintain confidentiality of all information obtained in the course of my employment including, but not limited to, financial, technical, or proprietary information of the organization and personal and sensitive information regarding patients, employees, and vendors. I understand that inappropriate disclosure or release of patient information is grounds for termination.

 

Upload resumé (optional):

Signature of Applicant: * (initials)

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.