Application for Employment

An Equal Opportunity Employer
We do not discriminate on the basis of race, religion, national origin, color, sex, age, veteran status, or disability. It is our intention that all qualified applicants be given equal opportunity and that selection decisions are based on job-related factors.

An asterisk (*) indicates information that must be filled in for the form to work.

Personal

Date
Social Security No.
* Full Name
* Email Address
Street Address
City
State
ZIP Code
Telephone
Position sought
Rate of pay expected (per week)
Would you work ...	Full-time     Part-time
Specify days and hours if part-time:
Were you previously employed by Otterkill Animal Hospital?	Yes     No
If yes, when:
List any friends or relatives working here, other than spouse:
On what date could you begin work?
Are there any work experiences, skills, or qualifications that you feel would especially fit you for work here? Please add any comments you think are important for us to consider.

If you are applying for a job with minimum age requirements, you might be required to submit proof of age.

Are you 18 years of age or older?

Yes     No

For driving jobs only: Do you have a valid driver's license?

Yes     No

Driver's license number:
Class of license:

Has your driver's license been revoked or suspended in the past three years?

Yes     No

If hired, can you furnish proof you are eligible to work in the United States?

Yes     No

Have you ever been convicted of a felony?

Yes     No

(A "yes" answer does not automatically disqualify you from employment since the nature of the offense, date, and the job for which you are applying will be considered.)

If yes, please explain:

Have you previously applied here?	Yes     No
If yes, when:
Have you worked for any firm under a different name (such as a maiden name)?	Yes     No
If yes, give name(s):

Personal References (not former employers or relatives)

Name and occupation		Address		Phone number
Name and occupation		Address		Phone number
Name and occupation		Address		Phone number

Membership in Professional or Civic Organizations
(do not include racial, religious, or nationality groups)

Name or description of organization		Dates of active participation		Offices held
Name or description of organization		Dates of active participation		Offices held
Name or description of organization		Dates of active participation		Offices held

Education Record (Nonveterinarians Only)

High School		Degree		GPA		Honors
College or University		Degree		GPA		Honors
Business, Trade, Correspondence or Night School		Degree		GPA		Honors
Other		Degree		GPA		Honors

Do you type?	Yes   No     Words per minute:
Do you know shorthand?	Yes   No     Words per minute:

List office machines or computers you know how to operate:

Education Record (Veterinarians Only)

High School		Degree		GPA		Honors
College or University (Preveterinary)		Degree		GPA		Honors
College or University (Veterinary Curriculum)		Degree		GPA		Honors

Postgraduate training, including internships (include dates and degrees awarded, if any):

Are you board certified?	Yes   No
Are you board eligible?	Yes   No

Which specialty board?

List continuing education courses attended in the past 18 months:

List the states in which you are licensed to practice along with license numbers:

Work History (beginning with the most recent, list all past employers, including any pertinent military experience)

Name of company
Business address
City
State
ZIP Code
Phone number
Type of business
Immediate supervisor
Dates employed
Job title
Earnings at hire
Earnings at termination
Reason for termination

Description of duties:

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Name of company
Business address
City
State
ZIP Code
Phone number
Type of business
Immediate supervisor
Dates employed
Job title
Earnings at hire
Earnings at termination
Reason for termination

Description of duties:

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Name of company
Business address
City
State
ZIP Code
Phone number
Type of business
Immediate supervisor
Dates employed
Job title
Earnings at hire
Earnings at termination
Reason for termination

Description of duties:

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Name of company
Business address
City
State
ZIP Code
Phone number
Type of business
Immediate supervisor
Dates employed
Job title
Earnings at hire
Earnings at termination
Reason for termination

Description of duties:

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IMPORTANT: If the following information is not entered correctly, your application form will NOT be received. If you enter the wrong code, you will see an error message on the next screen. If you use your "back" button on your browser to return to this page, you will have to refresh the page, which might mean losing all the information you have entered. Trying to enter the same security code again will NOT work. We require this step to keep automatic spam programs from accessing the form.

* In the center box, please enter the letters and/or numbers displayed at far right exactly as they appear. All letters are lowercase.

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Affidavit

I certify that all information I have provided in the application is true and complete. I understand that any false information or omission might disqualify me from further consideration for employment and might result in my dismissal if discovered at a later date. I understand that the employer might request an investigative consumer report from a consumer reporting agency. This report might include information as to my character, reputation, personal characteristics and mode of living obtained from neighbors, friends, former employers, schools, and others. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I might obtain a complete disclosure of the nature and scope of the investigation. I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employer (except as previously noted), past employers and organizations named in this application to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE.

I have read, understand, and by checking "yes" consent to these statements

Yes   No