Careers Employment Application Please complete the entire applicationEmployer InformationAlabama Specialty Clinic 1908 Cherokee Avenue SW Cullman, AL 35055 256-736-1460 It is the policy of Alabama Specialty Clinic to provide oqual employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age) disability, or veteran status.Applicant InformationApplicant Full Name(Required) First Last Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of years at this residenceDaytime PhoneEvening PhoneMobile PhoneSocial Security Number(Required)Drivers's License (State/Number)(Required)Emergency ContactWho should be contacted if you are involved in an emergency?Relationship to youAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Daytime PhoneEvening PhoneJob position applied for Clinical Non-Clinical Salary desiredperWho referred you to our company?Do you have any friends or relatives who work here? If yes, please list here:Have you applied to our company previously? Yes No When?How will you get to work?Are you willing to work any shift, including nights and weekends? Yes No If no, please state any limitations:If applicable, are you available to work overtime? Yes No If you are offered employment, when would you be available to begin work?If hired, are you able to submit proof that you are legally eligible for employment in the United States? Yes No Have you ever been convicted of a felony or misdemeanor? Yes No I was convicted ofI was convicted of __________________ on _______ (date) in ________ (city) , ___ (State)THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE EMPLOYMENT.Applicant SkillsCheck those skills that you have. List any other skills that may be useful for the job you are seeking. Enter the number of years of experience, and select the number that corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)Typing Yes Years of experienceAbility rating 1 2 3 4 5 Microsoft Office Suite (Word, xccl, etc.) Yes Years of experienceAbility rating 1 2 3 4 5 Answering telephones Yes Years of experienceAbility rating 1 2 3 4 5 Customer service Yes Years of experienceAbility rating 1 2 3 4 5 eClinicalWorks experience Yes Years of experienceAbility rating 1 2 3 4 5 Phlebotomy Yes Years of experienceAbility rating 1 2 3 4 5 Perform EKGs Yes Years of experienceAbility rating 1 2 3 4 5 Immunizations Yes Years of experienceAbility rating 1 2 3 4 5 DOT Physicals Yes Years of experienceAbility rating 1 2 3 4 5 Urine Drug Screens Yes Years of experienceAbility rating 1 2 3 4 5 Audiometry Yes Years of experienceAbility rating 1 2 3 4 5 Respiratory Fit Testing Yes Years of experienceAbility rating 1 2 3 4 5 Breath Alcohol Testing Yes Years of experienceAbility rating 1 2 3 4 5 Additional Skills Add a skill Add another skill First added skillYears of experienceAbility rating 1 2 3 4 5 Second added skillYears of experienceAbility rating 1 2 3 4 5 Applicant Employment HistoryList your current o most recent employment first. Please list all jobs (including self-employment and military service) that you have held, beginning with the most recent, and list and explain any gaps in employment. Current or most recent employer nameSupervisor nameAddressCity State ZipJob dutiesReason for leavingDates of Employment Employer nameSupervisor nameAddressCity State ZipJob dutiesReason for leavingDates of Employment Employer nameSupervisor nameAddressCity State ZipJob dutiesReason for leavingDates of Employment Employer nameSupervisor nameAddressCity State ZipJob dutiesReason for leavingDates of Employment Employer nameSupervisor nameAddressCity State ZipJob dutiesReason for leavingDates of EmploymentApplicant's Education and TrainingCollege/University name and addressDid you receive a degree? Yes No If yes, degree(s) receivedHigh School/GED name and addressDid you receive a diploma? Yes No If yes, diploma(s) receivedOther training (graduate, technical, vocational)Please indicate any current professional licenses or certifications that you holdAwards, honors, special achievementsMilitary service Yes No BranchSpecialized trainingReferencesList any two non-relatives who would be willing to provide a reference for you.NameAddressCity State ZipTelephoneRelationship NameAddressCity State ZipTelephoneRelationship Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employerUpload your resumeAccepted file types: pdf, doc, docx, rtf, odt, Max. file size: 6 MB.CertificationI certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for the rejection of my application or, if employment commences, immediate termination. I authorize Alabama Specialty Clinic to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. l authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education. If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Company Medical Director and Manager, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Alabama Specialty Clinic, except in a specific written contract of employment signed on behalf of the organization by its Company Medical Director and Manager, has the power to alter or vary the voluntary nature of the employment relationship. I HAVE CAREFULLY READ THE ABOVE CERTIFICATION, AND I UNDERSTAND AND AGREE TO ITS TERMS.Signature(Required)Date Month Day Year CAPTCHA Δ
