Mangrove Medical Group | Chico, CA

An Equal Opportunity Employer

Date

First Name

Middle Name

Last Name

Email Address

Phone Number

Present Address

No. & Street

City

State

Zip Code

Permanent Address (if different from present address)

No. & Street

City

State

Zip Code

Employment Desired

Position applying for:

Are you applying for:

Regular full-time work

Yes

No

Regular part-time work

Yes

No

Temporary work, e.g., summer or holiday work

Yes

No

Based on your experience what is the salary expectations for the position you are applying for?

Other than time off for reasons related to your religion, a disability or a medical condition, are there any days or times when you are unavailable to work?

Would you be available to work overtime, if necessary?

Yes

No

If hired, what date can you start work?

Personal Information

How did you hear about our company and this job opening?

Have you ever applied to or worked for Mangrove Medical Group before?

Yes

No

If yes, when?

If hired, would you have a reliable means of transportation to and from work?

Yes

No

Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.)

Yes

No

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?

Yes

No

If no, describe the functions that cannot be performed.

Note:

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)

Answer the following questions if you are applying for a professional position:

Are you licensed/certified for the job applied for?

Yes

No

Name of License/certification: License/certification:

Issuing State

Exp Date

Has your license/certification ever been revoked or suspended?

Yes

No

If yes, state reason(s), date of revocation or suspension, and date of reinstatement.

Education, Training, and Experience

High School

Name

Address

City

State

Zip Code

No. of Years Completed

Did you Graduate?

Yes

No

Degree or Diploma

College/ University

Name

Address

City

State

Zip Code

No. of Years Completed

Did you Graduate?

Yes

No

Degree or Diploma

Vocational/Business

Name

Address

City

State

Zip Code

No. of Years Completed

Did you Graduate?

Yes

No

Degree or Diploma

Health Care/Training

Name

Address

City

State

Zip Code

No. of Years Completed

Did you Graduate?

Yes

No

Degree or Diploma

Do you have any other experience, training, qualifications, or skills that you feel make you especially suited for work at Mangrove Medical Group?

Yes

No

If so, please explain:

Employment History

List below all present and past employment starting with your most recent employer (last five years is sufficient). You must complete this section even if attaching a resume.

1. Name of Employer

Phone Number

Type of Business

Your Supervisor's Name

Address & Street

City

State

Zip Code

Date of Employment

Date of Employment:

From

To

Your Position and Duties

Reason for Leaving

Current Employer?

Yes

No

May we contact this employer for a reference?

Yes

No

2. Name of Employer

Phone Number

Type of Business

Your Supervisor's Name

Address & Street

City

State

Zip Code

Date of Employment

Date of Employment:

From

To

Your Position and Duties

Reason for Leaving

Current Employer?

Yes

No

May we contact this employer for a reference?

Yes

No

3. Name of Employer

Phone Number

Type of Business

Your Supervisor's Name

Address & Street

City

State

Zip Code

Date of Employment

Date of Employment:

From

To

Your Position and Duties

Reason for Leaving

Current Employer?

Yes

No

May we contact this employer for a reference?

Yes

No

4. Name of Employer

Phone Number

Type of Business

Your Supervisor's Name

Address & Street

City

State

Zip Code

Date of Employment

Date of Employment:

From

To

Your Position and Duties

Reason for Leaving

Current Employer?

Yes

No

May we contact this employer for a reference?

Yes

No

References

List below three persons not related to you who have knowledge of your work performance within the last three years.

First Name

Last Name

Phone Number

Address & Street

City

State

Zip Code

Email

No. of Years Acquainted

Occupation

First Name

Last Name

Phone Number

Address & Street

City

State

Zip Code

Email

No. of Years Acquainted

Occupation

First Name

Last Name

Phone Number

Address & Street

City

State

Zip Code

Email

No. of Years Acquainted

Occupation

Please Read Carefully, Initial Each Paragraph and Sign Below

Initials

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

Initials

I hereby authorize Mangrove Medical Group to thoroughly investigate my references, work record, education and other matters related to my suitability for employment (excluding criminal background information) unless otherwise specified above. I further authorize the references I have listed to disclose to Mangrove Medical Group any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release Mangrove Medical Group, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I hereby authorize Mangrove Medical Group to thoroughly investigate my references, work record, education and other matters related to my suitability for employment (excluding criminal background information) unless otherwise specified above. I further authorize the references I have listed to disclose to Mangrove Medical Group any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release Mangrove Medical Group, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

Initials

I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and Mangrove Medical Group. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or Mangrove Medical Group, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Company's designated representative.

Initials

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

Mangrove Medical Group will consider qualified applicants, including those with criminal histories, in a manner consistent with state and local "Fair Chance" laws.

Mangrove Medical Group will consider qualified applicants, including those with criminal histories, in a manner consistent with state and local "Fair Chance" laws.

Date

Applicant's Signature

Employment Application

Employment Application