Homepage of North Pinellas Children's Medical Center, Florida Pediatricians

Application For Employment

Notice to Applicants: NPCMC is an equal opportunity employer and does not discriminate on the basis of an applicant's or employee's race, color, religion, sex, national origin, citizenship, age, physical or mental disability or any other characteristic protected by state or federal law

Application for Employment

Applicants may be tested for illegal drugs

Date: Social Security Number:
Last Name:
First Name:
Middle Initial:
Maiden Name:
Phone Number:
Address:
City:
State:
If you are under 18 years of age,
please specify your age here:
Position Applied For:
Desired Salary:
Days/Hours Available to Work:
      No Pref:       Thurs:
      Mon:       Fri:
      Tue:       Sat:
      Wed:       Sun:
How many hours can you work weekly?
Can you work nights? Yes          No
Employment desired: Full Time  Part Time
When are you available for work?
Have you ever worked with NPCMC before? Yes    No
      If yes, what Dates:
Prior position(s) held:
Reason(s) for Leaving:
Do you have any friends or relatives working for NPCMC? Yes          No
If yes, please state name(s) and relationship:
Name: Relation:
Were you referred by anyone? Yes          No
      Referred by:

Education

Name, City, State of Educational Institution: Number of Years Completed: Major & Degree:
High School:


College or University:


Technical/GED:


Licenses/Certifications/Other:


Military

Do you have any friends or relatives working for NPCMC? Yes          No
Are you now a member of the National Guard? Yes          No
Specialty:
      Date Entered:
      Date Discharged:

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. Attach additional sheets if necessary

Name of employer:
Address:
City:
State:
Zip Code:
Phone Number:
Name of last supervisor:
Employment Dates:
From: To:
Pay or Salary:
Start: Final:
Reason for leaving: (Please be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions:
Name of employer:
Address:
City:
State:
Zip Code:
Phone Number:
Name of last supervisor:
Employment Dates:
From: To:
Pay or Salary:
Start: Final:
Reason for leaving: (Please be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions:
Name of employer:
Address:
City:
State:
Zip Code:
Phone Number:
Name of last supervisor:
Employment Dates:
From: To:
Pay or Salary:
Start: Final:
Reason for leaving: (Please be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions:
May we contact your present employer? Yes          No
Did you complete this application yourself? Yes          No
      If not, who did?
Have you ever been convicted of a crime? Yes          No
If yes, explain number of convictions(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.

References

Please list two references other than relatives or previous employers.

Name:
Position:
Company:
Address:
Phone Number:
Name:
Position:
Company:
Address:
Phone Number:
Signature:    
Date: