Dayton Ohio Podiatrists

Employment Application
PLEASE READ BEFORE FILLING APPLICATION

All information and content herein belongs solely to Online Billing & Practice Management Services and Community Foot Specialist

All hiring, whether it is for Online Billing & Practice Management Solutions or Community Foot Speacialist, is done by Online Billing & Practice Management Solutions through our Enon office.
________________________________________________
1. Date *
MM
/
DD
/
YYYY
2. Name *
First
Last
3. Address *
Street Address
Address Line 2
City
State / Province / Region
Zip / Postal Code
Country
4. Phone Number *
5. Are you a U.S. Citizen or otherwise authorized to work in the U.S. on an unrestricted basis? *
Yes
No
You may be asked to provide documentation.
Position Applying For *
6. Have you ever been employed by OBMPS or Community Foot Specialist? *
Yes, OBMPS
Yes, Community Foot Specialist
No
7. Have you ever Applied to OBMPS or Community Foot Specialist ? *
Yes, OBMPS
Yes, Community Foot Specialist
No
7.1 When and where did you apply?
Please leave blank if you answered no to question previous question
8. Are you currently employed? *
Yes
No
9. May we contact your present employer? *
Yes
No
Check yes if unemployed
10. What type of employment are you looking for? *
Full-time
Part-time
Seasonal
Temporary
Check all that apply
11. If part time, what shift are you able to work?
Morning (8-12)
Afternoon (1-5)
If you are willing to work either, please select both.
12. Are you able to relocate? *
Yes
No
13. Have you ever been convicted of a felony? *
Yes
No
This will not necessarily affect your application consideration
13.1 If you answered yes to question 13, please explain the circumstances
14. Are you willing to travel? *
Yes
No
Start date *
MM
/
DD
/
YYYY

Please fill in the earliest date your are availble to start working.
16. Desired Salary *
$
Dollars
.
Cents

Please fill in desired HOURLY rate
Education
High School *
Please fill in High School & Date of graduation
College
Please fill in College and year of graduation (or predicted year of graduation)
Are you planning on continuing your studies? *
Yes
No
If yes, where and what courses of study
please list institutions / organizations and majors or concentrations
Training
Please fill in other professional training that you have received
Skills *
Please fill in any skills that you possess that you think are applicable to the job that you are applying for
Employment History (Start with most recent)
Empolyer 1
Company Name *
Address *
Street Address
Address Line 2
City
State / Province / Region
Zip / Postal Code
Country
Date Started *
MM
/
DD
/
YYYY
Starting Wage *
$
Dollars
.
Cents

Hourly rate
Starting Position *
Date Ended *
MM
/
DD
/
YYYY
Ending Wage *
$
Dollars
.
Cents

Hourly rate
Ending Position *
May we contact this employer? *
Yes
No
Responsibilities *
Reason for leaving *
Employer 2
Company Name 2 *
Company Address 2 *
Street Address
Address Line 2
City
State / Province / Region
Zip / Postal Code
Country
Date Started 2 *
MM
/
DD
/
YYYY
Starting Wage 2 *
$
Dollars
.
Cents

HOURLY RATE
Starting Position 2 *
Dated Ended 2 *
MM
/
DD
/
YYYY
Ending Wage 2 *
$
Dollars
.
Cents
Ending Position 2 *
May we contact employer 2 *
Yes
No
Responsibilities 2 *
Reason for leaving 2 *
Employer 3
Company Name 3
Company Adrdress 3
Street Address
Address Line 2
City
State / Province / Region
Zip / Postal Code
Country
Date Started 3
MM
/
DD
/
YYYY
Starting Wage 3
$
Dollars
.
Cents
Starting Position 3
Date Ended 3
MM
/
DD
/
YYYY
Ending Wage 3
$
Dollars
.
Cents
Ending Position 3
May we contact employer 3?
Yes
No
Responsibilities (3)
Reason for leaving (3)
References
Please list references name, address, phone number, nature of relationship, and years known.
Reference 1 *
Name, address, phone number, nature of relationship, and years known.
Reference 2 *
Name, address, phone number, nature of relationship, and years known.
Reference 3 *
Name, address, phone number, nature of relationship, and years known.
Emergency Contact
EC Name *
EC Address *
Street Address
Address Line 2
City
State / Province / Region
Zip / Postal Code
Country
EC Phone Number *
(###)
-
###
-
####
___________________________________________________
Please Read Before Singing
I certify that all information provided by me on this application is true and complete to the best of my knowledge and that i have withheld nothing that, if disclosed, would alter the integrity of this application.

I authorize my previous employers, schools, or person listed as references to give any information regarding employment or educational record. I agree that this company and my previous employers will not be held liable in any respect if a job offer is not extended, or is withdrawn, or employment is terminated because of false statements, omissions, or answers made by myself on this application. In the event that any employment with this company, I will comply with all rules and regulations as set by the company in any communication distributed to the employees.

In compliance with the Immigration Reform and Control Act of 1986, I understand that I am required to provide approved documentation to the company that verifies my right to work in the United States on the first day of employment. I have received from the company a list of the approved documents that are required.

I understand that employment at this company is "at will", which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statue. All employment is continued on that basis. I hereby acknowledge that I have read and understand the above statemets
Signature *
Please Sign bywriting your full name and dating it

[example: John Apple Seed, 09/12/1999]

Careers

Employment Application

Education

Employment History (Start with most recent)

Empolyer 1

Employer 2

Employer 3

References

Emergency Contact

Please Read Before Singing