About Us
Clinic
Physicians
Staff
Notice of Privacy Practices
Primary Care First & Medicare Shared Savings
Careers
Patient Portal
New Patient Inquiry
Patient Paperwork
Welcome to FPG
Demographics
Health History
Patient Health Questionnaire (PHQ-9)
Printable Forms
Medicare Wellness Form
Medical Minute
Satisfaction Survey
Family Physicians Group
About Us
Clinic
Physicians
Staff
Notice of Privacy Practices
Primary Care First & Medicare Shared Savings
Careers
Patient Portal
New Patient Inquiry
Patient Paperwork
Welcome to FPG
Demographics
Health History
Patient Health Questionnaire (PHQ-9)
Printable Forms
Medicare Wellness Form
Medical Minute
Satisfaction Survey
About Us
Clinic
Physicians
Staff
Notice of Privacy Practices
Primary Care First & Medicare Shared Savings
Careers
Application for Employment
Name
*
First Name
Last Name
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Position Applying For:
*
Select
CMA
MLT
LRT
LPN
Receptionist
Date Available to Start:
*
MM
DD
YYYY
How were you referred to this organization?
*
Since reaching the age 18, have you been convicted of a felony?
*
Yes
No
EDUCATION:
School Name and Address:
*
Course of Study:
*
Did You Graduate?
*
Yes
No
Professional Licenses/Certifications:
*
State Licenses/Certifications obtained:
*
PREVIOUS EXPERIENCE:
Job Title:
*
Employer Name and Address:
*
Employer Phone Number:
*
(###)
###
####
Job Duties:
*
Start Date:
*
MM
DD
YYYY
End Date:
Leave blank if still employed
MM
DD
YYYY
Reason for Leaving:
*
Last Salary:
*
$
Job Title:
*
Employer Name and Address:
*
Employer Phone Number:
*
(###)
###
####
Job Duties:
*
Start Date:
*
MM
DD
YYYY
End Date:
*
MM
DD
YYYY
Reason for Leaving:
*
Last Salary:
*
$
May we run an employment check from the employers listed above?
*
Yes
No
Please include any information you think would be helpful to us in considering you for employment such as additional work experience, publications, activities, accomplishments, etc.
I hereby affirm that the information provided on this application is true and complete to the best of my knowledge. I authorize persons, schools, my current employer (if applicable), and previous employers and organizations named in this application (and accompanying resume, if any) to provide any relevant information that may be required to arrive at an employment decision. My submission of this application serves as my signature.
*
First Name
Last Name
Signature Date:
*
MM
DD
YYYY
Thank you!