Job Application Form

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Date Available*

Social Security Number*

Driver's License Number (for purposes of a background check)*

Driver's License State of Issue*

Driver's License Expiration Date*

Position Applied For:*

Desired Salary*

Are you a citizen of the United States?*

Yes
No

If no: are you authorized to work in the US?

Yes
No

Have you ever worked for this company?*

Yes
No

If so: when?

Have you ever been convicted of a felony?*

Yes
No

If yes: explain

Education: High School*

Did you receive a degree?

Yes
No

Which High School did you attend?*

When did you graduate?*

Education: College*

Did you receive a degree?

Yes
No

If yes: what was your degree?*

Which College did you attend?*

When did you graduate?*

Reference Full Name

Relationship with Reference

Reference Company

Reference Phone Number

Reference Address

Reference Full Name

Relationship with Reference

Reference Company

Reference Phone Number

Reference Address

Upload Resume & Previous Work Experience*

Max. file size: 50 MB.

Signature*

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

RELEASE DISCLOSURE AND AUTHORIZATION*

In connection with my application for employment (including contract for services) or at any time during my employment or contract, I agree to all and hereby authorize Surgery Center of Fort Collins to procure and compile a consumer report or investigative consumer report on me. This report may include information as to my character, reputation, mode of living, criminal history, military service, education, academic credentials, qualifications, employment history (including job performance, experience, work habits and reason for termination), personal characteristics, credit and indebtedness, and motor vehicle driving record. This report may contain information from various public and private sources including without limitation, corporations, courts and law enforcement agencies at the federal, state or local level, courts record repositories, credit bureaus, departments of vehicles, past or present employers, educational institutions, governmental licensing or registration entities, the military, business or personal references, and any other source required to verify information that I have voluntarily supplied. I understand that I have that right to request additional disclosures as to the nature and scope of the investigative consumer report. Medical and worker’s compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. I understand that this report is subject to a federal law, The Fair Credit Reporting Act (FCRA), and that I have been provided with a copy of “A Summary of Your Rights under the Fair Credit Reporting Act”. According to the FCRA, I am entitled to know if employment is denied because of information contained in a consumer report and if employment is denied, I will be notified and provided with the name and address of the consumer-reporting agency (also indicated below). By signing below, I agree to allow and hereby authorize, empower and release from all liability, without reservation, any part, person or agency including, without limitation, present and former employers, credit bureaus, educational institutions, corporations, courts and law enforcement agencies at the federal, state or local level, courts record repositories, department of motor vehicles, educational institutions, the military and licensing or registration entities, contacted by Surgery Center of Fort Collins to release information about me, including, without limitation, any of the information described above. I agree that a fax, photocopy or electronic reproduction of this authorization is to be considered and accepted with the same authority as the original.

I authorize Surgery Center of Fort Collins to perform a background check.