Matthews-Vu Employment Application

Please complete this employment application. Please answer all questions.

Applicant Information

Application Date

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Position Desired

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If 'other', please list

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First Name

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Last Name

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Phone Number

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Current Address

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How long at current address?

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Previous Address

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How long at previous address?

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Have you ever been terminated from any job?*

Yes

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If yes, please explain

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Please explain any employment gaps greater than 3 months, to include month and year.

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Have you ever used another name?

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May we contact your current employer?*

Yes

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If no, please explain

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Do you have adequate transportation to and from work?*

Yes

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Are you available to work up to 40 hours per week, during hours of operation? Monday-Friday 7:00 am - 8:00 pm, Saturday 9:30 am - 3:00 pm and Sunday 11:30 am - 3:00 pm?*

Yes

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If no, please list availability

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Education

High School

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Did you graduate?*

Yes

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Undergraduate

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Did you graduate?

Yes

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Degree

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Graduate/Professional

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Did you graduate?

Yes

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Degree

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References

Name

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Position

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Phone

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Years Known

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Name

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Position

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Phone

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Years Known

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Name

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Position

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Phone

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Years Known

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Employment History

Present or Last Employer

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Title/Position

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Phone

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Address

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Name of Supervisor

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Dates Employed (From/To: Month/Year)

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Reason for Leaving

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2nd Previous Employer

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Title/Position

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Employer Phone

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Address

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Supervisor

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Dates Employed (From/To: Month/Year)

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Reason for Leaving

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3rd Previous Employer

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Title/Position

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Employer Phone

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Address

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Supervisor

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Dates Employed (From/To: Month/Year)

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Reason for Leaving

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Do you know or are you related to anyone who is currently employed by Matthews-Vu Medical Group?

Yes, No*

Yes

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If yes, please list:

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The above question is only served as a disclosure. Being related to another employee in no way makes you ineligible for employment.

Applicant Statement & Agreement

This application will be considered active for a maximum of 30 days. If you wish to be considered for employment after that time, you must reapply. My signature below attests that all of the information provided in this application is true and accurate.

In the event of my employment to a position in this Company, I will comply with all rules and regulations of this Company. I understand that the Company reserves the right to require me to submit to a test for the presence of drugs or alcohol in my system prior to employment and at any time during my employment, to the extent permitted by law and performed by a doctor selected by the Company. Further, I understand that at any time after I am hired, the Company may require me to submit to a physical examination and an alcohol test, to the extent permitted by law. I consent to the disclosure of the results of any physical examination and related tests to the Company. I also understand that I may be required to take other tests such as personality and honesty tests, prior to employment and during my employment. I understand that should I decline to sign this consent or decline to take any of the above tests, my application for employment may be rejected or my employment may be terminated. I understand that bonding may be a condition of hire. If it is, I will be so advised either before or after hiring and a bond application will have to be completed.

I understand that the Company may investigate my driving record and my criminal record and that an investigative consumer report may be prepared whereby information is obtained through personal interviews with my personal references, and others with whom I am acquainted. This inquiry includes information as to my character, general reputation, personal characteristics and mode of living. I understand that I have the right to make a written inquiry within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation.

I further understand that the Company may contact my previous employers and I authorize those employers to disclose to the Company all records and information pertinent to my employment with them. In addition to authorizing the release of any information regarding my employment, I hereby fully waive any rights of claims I have or may have against my former employers, their agents, employees and representatives, as well as other individuals who release information to the Company, and release them from any and all liability, claims, or damages that may directly or indirectly result from the use, disclosure, or release of any such information by any person or party, whether such information is favorable or unfavorable to me. I authorize the persons named herein as professional references to provide the Company with any pertinent information they may have regarding myself.

I hereby state that all the information that I provided on this application or any other documents filled out in connection with my employment, and in any interview is true and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am employed and any such information is later found to be false or incomplete in any respect, I may be dismissed. I understand if selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws require me to complete an I-9 Form in this regard.

In consideration of my employment, I agree to comply with the policies, rules, regulations, and procedures of the Company and I understand that my employment and compensation with the Company is at-will and can be terminated with or without cause or notice, at any time, at the option of either the Company or myself. This application is not an employment contract and acceptance of an offer of employment will not create an obligation to continue employment in the future.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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