The Children's Clinic Job Application Form

Basic Info

Date of application	Position/s applied for

Name	Address

City	State

Zip	Primary Phone

Secondary Phone	E-Mail

Your cover letter or a short introduction (optional)

Employment Information

Have you ever been employed here before? If yes, give dates and positions

Date available for work

What is your desired salary range

Type of employment desired

Have you ever pled "guilty" or "no contest" to, or been convicted of a felony? If yes, please provide date(s) and details

The Children's Clinic, P.C. conducts pre-employment criminal background checks and illegal drug screening tests on all prospective employees.

Answering "YES" to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

High School


Name and Location	Years Completed

Did You Graduate?	Course(s) of Study


College/Other Training

Name and Location	Years Completed

Did You Graduate?	Major/ Degree

Course(s) of Study

Employment History 1 (Last Job First)

Employer1	Employer1 Telephone

Employer1 Address	From - To

Starting Job Title	Final Job Title	Can we contact for reference?

Reason for Leaving	Summarize the nature of work performed and job responsibilities


Employment History 2

Employer2	Employer2 Telephone

Employer2 Address	From - To

Starting Job Title	Final Job Title	Can we contact for reference?

Reason for Leaving	Summarize the nature of work performed and job responsibilities


Employment History 3

Employer3	Employer3 Telephone

Employer3 Address	From - To

Starting Job Title	Final Job Title	Can we contact for reference?

Reason for Leaving	Summarize the nature of work performed and job responsibilities


Please enter in the characters shown below. Having a hard time reading? Move your mouse over the speaker...