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General Employment

Are you a healthcare provider passionate about children and promoting our community's optimal well-being? Please fill out the form below to apply for a general position within Mansoor Pediatrics.

Date: 11/25/2017 Email:
Last Name: First Name:
M.I.: Nick Name:
Place Of Birth:    
Present Address:
No. & Street: City:
State: Zip:
Parish/County: Home Phone:
Cell Phone: Social Security Number:
Date Of Birth: Click Here to Pick up the date Drivers License Number:
Drivers License State:    
Has Your License ever been suspended or revoked? Yes No
If Yes, state reason, date of revocation or suspension and date of reinstatement:
Position Applying for:
Are you currently employed? Yes No
If Yes, may we contact your current employer? Yes No
If hired, on what date can you start work? Click Here to Pick up the date
Salary/Hourly Wage desired: $
Were you referred to our company? Yes No if Yes,Who reffered you :
Have you ever been convicted of a crime(felony or misdemeanor)? Yes No
If Yes,state the nature of the crime(s), when and where convicted and disposition of the case:
Medical Information:
Doctor's Name: Address:
Phone Number: Blood Type:
Medical Condition: Allergies:
Current Medications:    
Emergency Information:
Emergency Contact's Names: Relationship:
Address: Phone Number(s) :
Educational, Training, Experience:
High School/No. of Years Completed: 
Did you Graduate? Yes No
College/Level: Vocational/Other:
List any certifications held
Employment History:
List below all present and past employment starting with your most recent employer(last five year is sufficient). Account for all periods of unemployment. You must compete this section even if attaching a resume. 
Employer 1
Company: Phone:
Address: Supervisor:
Job Title: Responsibilities:
From  Click Here to Pick up the date To  Click Here to Pick up the date
Reason for leaving:
May we contact your pevious supervisor for reference:
Yes  No
Employer 2
Company: Phone:
Address: Supervisor:
Job Title: Responsibilities:
From  Click Here to Pick up the date To  Click Here to Pick up the date
Reason for leaving:
May we contact your pevious supervisor for reference:
Yes  No
Employer 3
Company: Phone:
Address: Supervisor:
Job Title: Responsibilities:
From  Click Here to Pick up the date To  Click Here to Pick up the date
Reason for leaving:
May we contact your pevious supervisor for reference:
Yes  No
If there are any time gaps your employment please explain:
Additional Informaion:
Have you obtained any special skills or abilities as the result of service in the military? Yes No
If so , describe:
If hired ,can you present evidence of you U.S. citizenship or proof of your legal right to live and work in this country? Yes No
Are you at least 18 years of age? Yes No
If hired, would you have reliable means of transportation to and from work? Yes No
Have you ever been enjured on the job? Yes No
If Yes, explain :
Have you ever filed a Worker's Compensation claim? Yes No
If Yes, explain :
Have you ever filed a lawsuit against a former employer? Yes No
If Yes, explain :
Will you abide by safety, disciplinary and subtance abuse policies of this company? Yes No
Please Read Carefully:
This application is intended for use in eveluation your qualification for employment. This is not an employee contract.False,misleading or misinterpreted statements on this application are reason for termination of employment.All qualified applicants will receive consideration without discrimination of gender,marital status, race, age, creed, religion, national origin or the presence of disabilities.A felony conviction will not necessarily bar an applicant from employment. A pre-employment drug screen is required.A $50 charge will be assessed to pre-employment applicants with positive test results. Employees are subject to random drug screening. Your signature on this document confirms you understanding of the above mentioned policies.
  I Accept
Applicant's Signature Date: 11/25/2017
Thank you for your information. We will get back to you soon.