Myrtle Grove Animal Hospital is an equal opportunity employer and will not discriminate against race, religion, sexual orientation, color, age, sex, or disability. Selection decisions are based only on job-related factors.

Position applied for *

Date of application *

Where did you hear that we are hiring? *

Name *

First

Last

SSN *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Are you presently employed? *

Yes
No

Are you a citizen of the United States? *

Yes
No

If you are not a US citizen, are you authorized to work in the US? *

Yes
No

If applicable, please list your visa type, visa number and expiration date

Date available to begin work *

What is your desired salary range? *

Type of employment desired *

Full-time
Part-time

Have you ever been convicted of a crime? *

Yes
No

If yes, please provide dates and details *

Do you consent to a criminal background check? *

Yes
No

Do you consent to initial and periodic employee drug testing? *

Yes
No

Driver’s license number & state *

Have you had your driver’s license suspended or revoked in the last 3 years? *

Yes
No

If yes, please explain *

Position Information

Have you applied for a position with Myrtle Grove Animal Hospital before? *

Yes
No

Are you able to meet the physical performance requirements of the position as listed in the job advertisement for which you are applying? *

Yes
No

If not, please explain *

Have you ever been certified/licensed as a veterinary technician? *

Yes
No

In what state(s)? *

Have you ever been or are you currently licensed as a veterinarian? *

Yes
No

In what state(s)/countries? *

Has your license/certification in any state/country ever been revoked or suspended? *

Yes
No

If yes, please explain *

Skills & Qualifications

Please explain your reasons for wanting this position *

Please describe any computer skills you have *

Languages spoken (other than English) *

Summarize any special training, skills, licenses and certificates that may qualify you for the position for which you are applying. *

Employment History

Provide the following information regarding your past and current employers, assignments, or volunteer activities, starting with the most recent. Please explain any gaps in employment in the section below. Do NOT reference your resume.

Employer *

Employer phone *

Date employment started *

Date employment ended *

Employer address *

Address Line 1

Address Line 2

City

State

Zip Code

Job title *

Duties/responsibilities *

Supervisor's name *

Reason for leaving *

Beginning & ending pay rate *

May we contact for a reference? *

Yes
No
Later

What did you like best about this job? *

What did you like least about this job? *

Employer #2 *

Employer #2 phone *

Date employment started *

Date employment ended *

Employer #2 address *

Address Line 1

Address Line 2

City

State

Zip Code

Job title *

Duties/responsibilities *

Supervisor's name *

Reason for leaving *

Beginning & ending pay rate *

May we contact for a reference? *

Yes
No
Later

What did you like best about this job? *

What did you like least about this job? *

Employer #3 *

Employer #3 phone *

Date employment started *

Date employment ended *

Employer #3 address *

Address Line 1

Address Line 2

City

State

Zip Code

Job title *

Duties/responsibilities *

Supervisor's name *

Reason for leaving *

Beginning & ending pay rate *

May we contact for a reference? *

Yes
No
Later

What did you like best about this job? *

What did you like least about this job? *

Additional comments (including explanation of any gaps in employment)

Educational Background

High School

High school name *

High school address *

Address Line 1

Address Line 2

City

State

Zip Code

Did you graduate? *

Yes
No

If you did not graduate, did you receive your GED? *

Yes
No

Special honors or awards

Technical or Vocational School

Did you go to a technical or vocational school? *

Yes
No

School name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Did you graduate? *

Yes
No

Degree or Certification *

Specialty *

Special honors or awards

College or University

Did you go to college or university? *

Yes
No

College/university name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Did you graduate? *

Yes
No

Degree *

Major *

Special honors or awards

Certificates or Licenses

Type of certificate/license

License #

Date issued

State issued

Current through

References List name and telephone number of three business/work references that are NOT related to you, and are NOT previous supervisors. If not applicable, list three school or personal references that are not related to you.

Reference #1 name *

First

Last

Reference #1 phone *

Number of years known *

Reference #2 name *

First

Last

Reference #2 phone *

Number of years known *

Reference #3 name *

First

Last

Reference #3 phone *

Number of years known *

Days/Hours Available For Work All staff are required to work Saturdays, Sundays, and holidays.

Please indicate the days and hours available below. *

Applicant Statement Request, Authorization, and Consent for Release of Information to Employer and Release from Liability for Disclosure of Information

I certify that all information I have provided in order to apply for and secure work with Myrtle Grove Animal Hospital is true, complete, and correct. I understand that in connection with the application process, Myrtle Grove Animal Hospital may request information from my past employers, educational institutions, personal references, and any other public or private agencies that have issued me either a professional or vocational certification or license. I also understand that such an investigation may include a review of any criminal records. I have provided complete and truthful information to Myrtle Grove Animal Hospital regarding all sources of information about my past employment, education, licensure, and/or certification and am aware that any misrepresentations or material omissions concerning such information will be grounds for denying me employment, withdrawing any offer of employment, or immediate discharge regardless of when such misrepresentation or material omission is discovered. In order to assist Myrtle Grove Animal Hospital in obtaining documents and information to confirm my background, if necessary, I hereby consent to the release of information more specifically described on the following page. *

I have read and agree

Request, Authorization, and Consent to Release of Employment Information and Education Records

I request, authorize, and consent to the release of information to Myrtle Grove Animal Hospital regarding my previous employment, and authorize all past employers or agents that they may designate, to respond to verbal or written inquires from Myrtle Grove Animal Hospital regarding my employment record, including, but not limited to, positions held, dates of employment, last pay rate, work performance, disciplinary records, reliability, and any incidents of dishonesty, insubordination, violence, and/or unsafe, harmful, or threatening behavior, including information based upon materials in my personal files. I also request, authorize, and consent to the release and disclosure to Myrtle Grove Animal Hospital of educational records from any and all public or private educational institutions that I have attended, including all records of my academic performance, courses attended, grades earned, diplomas, degrees, or other certificates conferred. *

I have read and agree

Request, Authorization, and Consent to Release of Personal Reference Information

I request, authorize, and consent to Myrtle Grove Animal Hospital contacting the personal references identified in my application for employment. I specifically request, authorize, and consent to Myrtle Grove Animal Hospital’s verbal or written inquires addressed to my personal references about the information contained in my application, as well as my reliability, honesty, and potential tendency, if any, to engage in any form of violence or other harmful, unsafe, or threatening behavior. *

I have read and agree

Request, Authorization, and Consent to Release of Licensing or Certification Information

I request, authorize, and consent to the release of information from any public agency or private entity concerning any professional or vocational license or certification that I have held in the past or currently hold, including, but not limited to, information concerning whether such license or certification is in good standing and any disciplinary or other proceedings concerning such license or certification. *

I have read and agree

Request, Authorization, and Consent to Investigation of Criminal Records and Driving Records

I request, authorize, and consent to Myrtle Grove Animal Hospital’s thorough investigation of whether I have a record of criminal convictions, and if so, the nature of such criminal convictions and all surrounding circumstances available through lawful means. Myrtle Grove Animal Hospital has advised me that its criminal background check will focus on convictions and that a criminal record will not necessarily disqualify me from employment. I also request, authorize, and consent to Myrtle Grove Animal Hospital’s thorough investigation of my driving record. *

I have read and agree

Request, Authorization, and Consent to Release of Credit Information

I request, authorize, and consent to the release of information to Myrtle Grove Animal Hospital regarding my credit history. *

I have read and agree

Applicant Statement and Release of Claims

I further hereby release and hold harmless Myrtle Grove Animal Hospital, its officers, employees, agents, and any other person, or public or private entity inquiring about, investigating, furnishing, communicating, reviewing, or evaluating information or documents pursuant to this Request, Authorization, Consent and Release, or making any written or verbal communications for such purposes, from any and all claims arising from such activities, including, but not limited to, any claims whatsoever for defamation, fraud, misrepresentation, intentional or negligent interference with prospective business relations of contract, breach of contract (including any settlement agreement), negligent or intentional infliction of emotional distress, violations of applicable federal or state laws governing employee references and/or disclosures of employment information, and any other potential claims, demands, damages, liabilities, and/or actions of any kind whatsoever, whether known or unknown to me presently, that I may have, now or in the future. I voluntarily grant this release for purposes of supporting my application for employment and based upon my desire to encourage Myrtle Grove Animal Hospital’s consideration of my application. I understand that I may raise with Myrtle Grove Animal Hospital any concerns I might have about the information that may be provided to Myrtle Grove Animal Hospital during its investigation of my application. I additionally agree to fully cooperate with Myrtle Grove Animal Hospital in permitting the release of the above information and reports. I additionally understand that all information and documents generated, received, or maintained by Myrtle Grove Animal Hospital during, or as a result of, its investigation, will be maintained as confidential information and that Myrtle Grove Animal Hospital will not release such information or documents to me, except as otherwise required by applicable federal, state, or local law. I understand that Myrtle Grove Animal Hospital 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 60 days. At the conclusion of this time, if I have not been offered a position by Myrtle Grove Animal Hospital and again wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I will be offered employment terms suitable to my position and that am free to resign at any time, with or without cause and that Myrtle Grove Animal Hospital reserves the same right to terminate my employment at any time, with or without cause or according to the terms of any contract with Myrtle Grove Animal Hospital as put forth in a subsequent document. This employment application does not, of itself, constitute an agreement or contract for employment for any specified period or definite duration, nor is it an offer of any particular position or described job. I understand that no supervisor or representative of Myrtle Grove Animal Hospital is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless executed in writing and signed by the Myrtle Grove Animal Hospital Owner or Hospital Administrator. 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 certify that I have read, fully understand, and accept all the terms of the foregoing Applicant Statement, AND I CERTIFY THAT I HAVE READ AND CAN PERFORM ALL THE TASKS IN THE JOB DESCRIPTION FOR THE POSITION FOR WHICH I AM APPLYING.

Signature *

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