Employment Application

Education and Military

Did you serve in the military?*

Yes
No

Dates served*

Branch of Service*

U.S. Army
U.S. Air Force
U.S. Marine Corps
U.S. Navy
U.S. Coast Guard
Merchant Marine

Highest rank obtained*

Education Details*

(Add a line for each educational institution: high school, associate's degree, undergraduate degree, graduate degree, etc.)

Institution Name	Location	Degree

Professional Licenses and Certifications

(Please list any professional licenses or certifications you have earned.)

Type	State	Expiration Date	Registration No.

Disciplinary Actions

Do you have any disciplinary action pending against your license/certification?

Yes
No

Past Disciplinary Actions

Have you ever had disciplinary action taken against your license/certification in Arkansas or in any other state?

Yes
No

Work History

(Please list all work history, beginning with your present employer or the most recent. Include periods of military service. If any information is not recalled, so note.)

Are you presently employed?*

Yes
No

Why do you wish to change jobs?

Work*

(Enter the details for each job, starting with present or most recent.)

Company Name	Position	Dates of Employ	Ending Salary	Reason for leaving	Telephone

May we contact your present employer?*

Yes
No

References

(Please provide references [not employers or relatives] who are acquainted with your work history.)

References*

(Please list four references.)

Name	Occupation	Phone

Resume Upload

Please upload a PDF of your resume.

Additional Information

Comments

(Please make any comments you feel are pertinent to your application.)

Clarification Information

(If there is any additional information necessary to enable a check of your records, such as a change of name, use of an assumed name or nickname, please describe here.)

I authorize you to obtain information from any source as to my education, experience, competence, character or medical history as is related to the position for which I applied. I certify the information contained in this application is true and correct to the best of my knowledge. I understand that any falsification or omission of information may cause an immediate dismissal or rejection of this application. I agree that all statements made in this application may be investigated. I understand that I may be required to complete a medical exam for initial and continued employment. I understand that if I am employed, employment is at will. Neither I, nor the employer, have agreed to any specific time of employment, pay or benefits unless otherwise set forth in a separate contract. Further, in making this application for employment, it is understood and accepted that as a part of this application and employment process, and/or during employment, I may be asked to submit to random physical examinations which may include testing for alcohol and drugs, all in accordance with the law. By signing this application, I hereby agree to submit to such examinations and tests and release all persons, and companies, including Medical Associates of Northwest Arkansas, from any liability arising out of such examinations and tests. I further agree to the release of the results of any examinations to Medical Associates of Northwest Arkansas. Further, in making this application for employment, I specifically request, authorize, and consent to Medical Associates of Northwest Arkansas’ thorough investigation of whether I have a record of criminal convictions and, if so, the nature of such criminal convictions and all surrounding circumstances available through lawful means. It is also known to me that Medical Associates of Northwest Arkansas’ criminal background check will focus on convictions and that a criminal record will not necessarily disqualify me from employment. I request, authorize and consent to the foregoing parties to provide the requested information to Medical Associates of Northwest Arkansas and release them and Medical Associates of Northwest Arkansas from any liability arising there from. I authorize all of my prior employees, credit bureaus, the officials of all schools which I have attended or been associated with, any person named on my application, and any other entity or person to give information regarding my employment, personal habits, ability, criminal record or any other relevant information regarding my employment, personal habits, ability, criminal record, or any other relevant information they may have regarding me whether or not it is on their records. I release these individuals and entitles from any and all liability for any damage whatsoever which might result from their furnishing this information. If employed, I agree to follow all policies, practices, and procedures of MANA and acknowledged that these may be changed, interpreted, withdrawn, or amended by MANA at any time, at MANA’s sole option, without any prior notice to me. I consent and agree that MANA has the right to search my personal property located on MANA’s property, along with MANA’s desk, closet, et cetera, for the purpose of investigating possible violations of MANA’s rules / policies. This means that MANA also has the right to access my telephone conversations and e-mails or other types of electronic communications. A copy of the form shall serve as an original. I WARRANT AND REPRESENT THAT ALL FACTS GIVEN ON THIS APPLICATION ARE CORRECT TO THE BEST OF MY KNOWLEDGE AND I ACKNOWLEDGE AND AGREE THAT ANY MISREPRESENTATION OR OMISSION ON THIS APPLICATION IS CAUSE FOR REJECTION OR TERMINATION.

Signature*

(Type your name below, which will count as your signature on this form.)

Step 1 of 2

Personal Information

Job Position Information

Education and Military

Work History

References

Additional Information