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Learn more or submit your application by e-mailing careers@pioneerphysicians.com

Employee Application Form

I understand that neither this application nor any communication by a management representative is intended to create or does create a contract of employment, offer, or promise of employment for a definite term. I acknowledge that if hired by the company, employment is on an at-will basis in accordance with state law. This means the company is free to terminate my employment at any time, with or without cause or advance notice, in accordance with state law, and acceptance of employment is not a contract of employment for any specified time. Similarly, I am free to terminate my employment with the company at any time for any reason. This at-will provision may be modified or waived only in a written agreement signed by an authorized representative of the company and me. I agree to conform to the rules and regulations of the company, and I understand that the company has complete discretion to modify such rules and regulations at any time, except that it will not modify its policy of employment at-will or its arbitration policy, if any.

INFORMATION

How did you hear about us?
Type of employment desired
Can you travel if the job requires it?
Best time to contact you is:
We are an equal opportunity employer. Applicants are considered for positions without regard to race, religion, gender, national origin, age, disability, or any other consideration made unlawful by applicable federal, state, or local laws
If under the age of 18, can you produce the necessary work certificate at the time of employment?
Have you previously applied for employment with Pioneer Physicians Network, Inc.?
Have you ever been employed with us before?.
Are you currently employed?
May we contact your present employer?
Are you legally eligible to become employed in the United States? Proof of citizenship or immigration status will be required upon employment

Instructions for the next two questions: Do not include convictions that were sealed, eradicated, erased, annulled by a court, or expunged, or convictions that resulted in referral to a diversion programs.

Have you ever plead guilty or no contest to, or been convicted of any criminal offense other than the applicable exceptions listed above?
Have you ever been arrested for any matters for which you are out on bail or on your own recognizance pending trial?

Criminal convictions or arrests will not automatically disqualify an applicant from a particular job. The Company will consider the nature of the crime, its seriousness, whether the conviction(s) substantially relates to the position’s functions and qualifications, the frequency of convictions, the applicant’s age at the time of conviction, the time elapsed since the date of conviction or completion of jail sentence, the applicant’s entire work and educational history, and employment references and recommendations.

Have you ever initiated an act of violence in the workplace?

EDUCATION

WORK EXPERIENCE 1

May we contact?
Do you have additional work experience?

WORK EXPERIENCE 2

May we contact?
Do you have additional work experience?

WORK EXPERIENCE 3

May we contact?
Do you have additional work experience?

WORK EXPERIENCE 4

May we contact?

ADDITIONAL WORK INFORMATION

Have you ever been terminated or asked to resign from any job?
Has your employment ever been terminated by mutual agreement?
Have you ever been given the choice to resign rather than be terminated?

OTHER QUALIFICATIONS

REFERENCES

Please list the names of additional work-related references we may contact. Individuals with no prior work experience may list school or volunteer references.

(i.e. supervisor, co-worker)
(i.e. supervisor, co-worker)
(i.e. supervisor, co-worker)

Please list the names of personal references (not previous employers or relatives) who know you well that we may
contact.

APPLICANT CERTIFICATION

I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver’s license and automobile liability insurance in an amount equal to the minimum required by the state where I reside.

I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law. If the Company has such a program and I am offered a conditional offer of employment, I understand that if a preemployment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state and local law. I also understand that all employees of the location, pursuant to the Company’s policy and federal, state, and local law, may be subject to urinalysis and/or blood screening or other medically recognized tests as a condition of continued employment and I agree to undergo alcohol and drug testing consistent with the Company’s policies and applicable federal, state, and local law.

If employed by the Company, I understand and agree that the Company, to the extent permitted by federal, state, and local law, may exercise its right, without prior warning or notice, to conduct investigations of property (including, but not limited to, files, lockers, desks, vehicles, and computers) and, in certain circumstances, my personal property.

I understand and agree that as a condition of employment and to extent permitted by federal, state, and local law, I may be required to sign a confidentiality, non-compete, and/or conflict of interest statement.

I certify that all the information on this application, my resume, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.

I authorize the Company or its agents to confirm all statements contained in this application and/or resume as it relates to the position I am seeking and
to extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation.

I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above-mentioned information. I hereby release the Company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the Company and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information.

If hired by this Company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this Company. I also understand this Company employs only individuals who are legally eligible to work in the United States for this Company.

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF SIXTY (60) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE.

If the applicant is a minor, the foregoing release and consent must be signed by the applicant’s parent or legal guardian. Signature by the applicant’s parent or legal guardian constitutes acknowledgement by the applicant and the parent or legal guardian that the Company, to the extent permitted by federal, state, and local law can test the applicant for controlled substances, conduct inspections of property without notice, and communicate screen results to Company personnel who need to know, the applicant, and the applicant’s legal guardian.

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