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64 W. Fifth St. Winona, MN 55987
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Rohrer Center Orthodontics
APPLICATION FOR EMPLOYMENT
Position Applied For
Date of Application
Present Address (Street, City, State, Zip Code)
Home Telephone Number
Message Telephone Number
If No Phone, How May We Contact You?
Click the + button on the far right to add additional addresses
Are Any of Your Relatives Presently Employed With This Business Or Its Divisions?
If Yes, Who?
Have You Ever Worked For This Business Or Its Divisions Before?
If Yes, Where?
Approximate Date: Month/Year
Have You Ever Applied For Employment With This Business Or Its Divisions Before?
If Yes, Where?
Approximate Date: Month/Year
How Were You Referred?
Are You 18 years Of Age Or Older?
Only U.S. Citizens Or Aliens Who Have A Legal Right To Work In The U.S. Are Elgible For Employment. Can You, Upon Employment, Provide Genuine Documentation Establishing Your Identity And Elgibility To Be Legally Employed In The United States?
Please Check Schedule Availability
I am available and desire to work FULL-TIME. Full-Time employees must be available for all/rotating shifts.
I am available and desire to work PART-TIME
I am only available for PART-TIME because:
If Other, Explain
Monday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)
Tuesday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)
Wednesday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)
Thursday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)
Friday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)
Saturday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)
Sunday: Time Available FROM (A.M. or P.M.) & Time Available TO (A.M. or P.M.)
Note: Work Schedules Are Based Upon The Needs Of The Business And May Be Subject To Change On A Weekly Basis.
Date Available For Work?
Begin With Your Most Recent Employment (1) And Continue With All Past Employment
City, State, Zip Code
Employed From (mm/yyyy)
Employed To (mm/yyyy)
Starting Salary ($)
Ending Salary ($)
Reason for Leaving
Name & Title of Supervisor
Type of Business
May We Contact Employer?
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Explain Any Period Between Jobs
ATTENDANCE AND PUNCTUALITY INFORMATION
Consistent attendance and punctuality are essential requirements of every job with this business. Is there anything which would interfere with your regular attendance and punctuality if you are offered a job with this business?
Education History - List High School and any post High School education. Click the + button on the far right to add additional high schools, colleges, universities, technical colleges, or trade schools
Type of School
Name and Address Of School
Highest Grade Or Year Completed
Click the + button on the far right to add additional high schools, colleges, universities, technical colleges, or trade schools
Military Training or Experience
PERSONAL OR BUSINESS REFERENCES
Add 4 References
Occupation Business Phone Number
Click the + button on the right to add additional references
Summarize special job-related skills and qualifications acquired from employment or other experience.
NOTIFICATION AND AGREEMENT
I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE, I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR H0W DISCOVERED.
Questions regarding this statement should be directed to any employment interviewer before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.
It is the policy of the company to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status, expunged juvenile records, or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, any and other characteristic protected by Federal, State or Local law.
I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation.
If hired, I agree to abide by all of the company rules and regulation, and understand that, if employed, my employment may be terminated with or without cause, and with or without notice, at any time, at the option of either the company or me, I further understand that no representation, whether oral or written by any representative or agent of the Company, at any time, can constitute a contract of employment. I understand that the Company and all Plan Administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms or conditions of employment. No representative or agent of the company, has the authority to enter into any agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by the President or Executive Vice President, or to make any agreement contrary to the foregoing.
I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me
Signature (Type your initials)
DO NOT SUBMIT UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT