7367 LEE HIGHWAY
P.O. BOX 3512
RADFORD VA.24141
(540) 639-3891, [email protected]
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: _____________________________
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Please write a short paragraph about yourself emphasizing the skills and personal characteristics that you believe qualify you for this job: _____________________________________________________________________________________
_____________________________________________________________________________________
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Name and location of highest level of school or vocational training:
Name & Location Graduated? Y or N Degree Major
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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."
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Signature Date
