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RADFORD ANIMAL HOSPITAL

7367 LEE HIGHWAY

P.O. BOX 3512

RADFORD VA.24141

(540) 639-3891, rahinfo@ntelos.net

APPLICATION FOR EMPLOYMENT

It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin, or other protected classification. We will retain all submitted applications for six months.

Name:__________________________________ Date: ________________________________

Last First Middle

Address: _____________________________________________________________________________

Street City State Zip

Email address:_______________________________________________________________________

Telephone: __________________ Social Security#: ________________________________

Do you have the right to work in the United States? Yes____ No____ On a restricted basis? Yes___ No___

Have you applied here previously? Yes___ No___ Do you have pets? Yes___ No___

What kind of pets do you have? ______________________________________________________

How did you learn about this opening? ____________________________________________________ Are there any hours, shifts, or days you cannot or will not work? _________________________________

Shifts preferred: ______________________________ Part-time ______ Full-time ______

Are you aware that working in a Veterinary Hospital may require you to work extra hours or overtime on some days in order to provide emergency care for our patients? Yes___ No___

Are you willing to work these extra hours? Yes___ No___

Have you ever been convicted of a felony or any crime involving theft? Yes___ No? ___

Note: A conviction will not necessarily disqualify an applicant for employment. The circumstances of any conviction will be considered in light of the position that you are seeking.

If yes, please describe the circumstances surrounding the conviction: _____________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Please write a short paragraph about yourself emphasizing the skills and personal characteristics that you believe qualify you for this job: _____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Name and location of highest level of school or vocational training:

Name & Location Graduated? Y or N Degree Major

_____________________________________________________________________________________________

Position applied for: ___________________ Wage or salary desired? ________________________

When could you start? __________________________________________

WORK HISTORY: May we contact your present employer? Yes___No___

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Most recent employer:

___________________________________________________________________________

Name Address Phone #

Start Date: _________ Starting Pay: __________ Starting Position: ____________________

End Date: _________ Ending Pay: ___________ Ending Position: _____________________

Description of duties: ____________________________________________________________________

Name and Title of Supervisor: _____________________________________________________________

Reason for leaving: ______________________________________________________________

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Previous Employer:

_____________________________________________________________________________________

Name Address Phone #

Start Date: _________ Starting Pay: __________ Starting Position: ______________

End Date: __________ Ending Pay: ___________ Ending Position: _____________________

Description of Duties: ____________________________________________________________________________

Name and Title of Supervisor: ________________________________

Reason for leaving: _______________________

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Previous Employer: _____________________________________________________________________________

Name Address Phone #

Start Date: __________ Starting Pay: ___________ Starting Position: ______________

End Date: __________ Ending Pay: ____________ Ending Position: ______________

Description of Duties: ____________________________________________________________________________

Name and Title of Supervisor: ________________________Reason for Leaving: ____________________

Authorization

" I certify that the facts contained in this application are true to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you all information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of any such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative."

__________________________________ ________________

Signature Date