EmailMe Form - Application

Position(s) applied for: *

Ancillary Assistant - Yankton

Lab Tech - Vermillion

Other

Patient Coordinator - Urology

Phlebotomist - Full Time

Phlebotomist - Part Time

Physician Assistant - Internal Medicine

Receptionist - Laboratory

Receptionist - Vermillion

RN/LPN/CMA - Phone Ortho/Rheumatology

RN/LPN/CMA - Urology

RN/LPN/CMA - Float Full Time

RN/LPN/CMA - Float Part Time

RN/LPN/CMA - Phone OB/GYN

RN/LPN/CMA - Physical Med Part Time

Name *

First Last

Email *

Home Phone

### - ### - ####

Mobile Phone *

### - ### - ####

Address *

Street Address City State / Province / Region Postal / Zip Code

How did you learn about us?

Are you willing to work?

Overtime

On-Call

Evenings / Weekends

When can you start?

MM / DD / YYYY

Salary Desired

Are you currently employed?

Yes

No

Are you prevented from lawfully becoming employed in this country because of visa or immigration status? Proof of citizenship or immigration status will be required upon employment.

Yes

No

Have you been known by another name?

Yes

No

If yes, please list your previous name(s).

Have you ever been convicted of a felony?

Yes

No

If yes, explain: (conviction will not necessarily disqualify an applicant from employment)

Education Information:

Please list Name / Location of school and Diploma / Degrees earned:

High School

College

Graduate School

Professional License # (if applicable)

Other (Specify)

Work History:

List your most recent employer first. You may include military and service training.

Past Employer #1:

Job Title

Employer

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Dates Employed
From:

MM / DD / YYYY

Dates Employed
To:

MM / DD / YYYY

Work Performed

Salary

Reason for Leaving

Supervisor Name *

First Last

Email *

Phone *

### - ### - ####

May we contact?

Yes

No

Past Employer #2:

Job Title

Employer

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Dates Employed
From:

MM / DD / YYYY

Dates Employed
To:

MM / DD / YYYY

Work Performed

Salary

Reason for Leaving

Supervisor Name *

First Last

Email *

Phone *

### - ### - ####

May we contact?

Yes

No

Past Employer #3:

Job Title

Employer

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Dates Employed
To:

MM / DD / YYYY

Dates Employed
From:

MM / DD / YYYY

Work Performed

Salary

Reason for Leaving

Supervisor Name

First Last

Email

Phone

### - ### - ####

May we contact?

Yes

No

Other Qualifications:

Summarize special job-related skills and qualifications acquired from education, employment, or other experiences.

Upload Your Resume

Word or PDF Documents Only

References:

List people who know your work. Do not include personal references.

Reference #1:

Name

First Last

Title / Occupation

Email *

Phone *

### - ### - ####

Reference #2:

Name *

First Last

Title / Occupation

Email *

Phone *

### - ### - ####

Reference #3:

Name *

First Last

Title / Occupation

Email *

Phone *

### - ### - ####

THE FOLLOWING POINTS ARE VERY IMPORTANT. PLEASE READ THEM CAREFULLY BEFORE SIGNING THIS APPLICATION

I authorize investigation of all statements contained in this application. I will not hold Yankton Medical Clinic, P.C. or any of my previous employers liable in any respect if an employment offer is not forthcoming, is withdrawn, or if my employment is terminated as a result of misrepresentation or omission of facts on this application. I understand that if I am employed by Yankton Medical Clinic, P.C. additional personal data may be required for determination of benefits, statistical purposes, and legal compliance.

I also understand that if I am employed by the Clinic, my employment is “at will”, that I or the Clinic may terminate the employment relationship at any time, for any reason, with or without notice. I further understand that no employee of the Clinic has the authority to modify this understanding orally or in writing, except with the written permission of the Chief Operating Officer of Yankton Medical Clinic, P.C.

I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE STATEMENTS AND UNDERSTAND EACH AND ALL OF THESE STATEMENTS.

Signature: *

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