Country Doctor Veterinary Hospital

6807 Weiss Road
New Tripoli, PA 18066

(610)298-2520

cdvh.com

APPLICANT STATEMENT

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

 

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal & professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I also understand the employer will perform a background check. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

 

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.

 

This application does not constitute an agreement or contract for employment for any specified period or definite duration.

I also understand that if I am hired, I will be required to provide proof of 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.

 

I understand that a negative drug test result is required by the employer prior to employment to comply with the employer?s drug-free workplace program.

 

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to cancel further consideration of this application, or immediately discharge me from the employer?s service, whenever it is discovered.

Employment Application

Date of Application

Position Applied For

Referred to our hospital by

Name
First Name
Last Name
Address
Street Address
City
,
State / Province
Zip / Postal Code
E-Mail Address :
Phone
Phone TypePhone Number
Phone
Phone TypePhone Number
Alternate Contact Phone
Phone TypePhone Number
Best Time To Call

May we contact you at work? Yes/No. If yes, work phone

Are you at least 18 years of age? :
Have you applied for a position previously? If yes - date & position applied for

Are you legally eligible for employment in this country? :
Date available to start work

Desired salary/hourly rate

Type of employment desired - Full time, part time, seasonal :
Are you able to meet the attendance requirements of the position? :
Are you able to perform the requirements described in the job description? :
Will you work overtime if required? Yes/No. If no, please explain

Have you ever pled "guilty" or "no contest" to, or ever been convicted of a crime? :
If yes, please provide date(s) and details

Are there any animals you cannot work with? Yes/No. If yes, please explain

EMPLOYMENT HISTORY
1. Employer & Telephone

Please start with your most recent employer and provice the following information
Dates Employed

Address
Street Address
City
,
State / Province
Zip / Postal Code
Job Title

Starting and Ending Wage

Immediate Supervisor/Title

Reason for Leaving
May we contact for reference? Yes/No/Later :
Please summarize your job responsibilities
2. Employer & Telephone

Dates Employed

Address
Street Address
City
,
State / Province
Zip / Postal Code
Job Title

Starting and Ending Wage

Immediate Supervisor/Title

Reason for Leaving

May we contact for reference? Yes/No/Later :
Please summarize your job responsibilities
3. Employer & Telephone

Address
Street Address
City
,
State / Province
Zip / Postal Code
Dates Employed

Job Title

Starting and Ending Wage

Starting and Ending Wage

Immediate Supervisor/Title

Reason for Leaving
May we contact for reference? :
Please summarize your job responsibilities
SKILLS & QUALIFICATIONS
Microsoft Office/OpenOffic/Internet/Intravet

Summarize any training, skills, licenses and/or certifications that may qualify you
EDUCATIONAL BACKGROUND
1. School (Include City & State)
# of years completed

Level of completion/Degree

Course of Study

2. School (Include City & State)
# of years completed

Level of completion/Degree

Course of Study

3. School (Include City & State)
# of years completed

Level of completion/Degree

Course of Study

4. School (Include City & State)
# of years completed

Level of completion/Degree

Course of Study

REFERENCES (persons not related to applicant)
First Reference
First Name
Last Name
Title/Profession

Relationship to applicant

Phone
Phone TypePhone Number
# of years known

Second Reference
First Name
Last Name
Title/Profession

Relationship to applicant

Phone
Phone TypePhone Number
# of years known

Third Reference
First Name
Last Name
Title/Profession

Relationship to applicant

Phone
Phone TypePhone Number
# of years known


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