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General Dermatology 757-622-6315; Cosmetics 757-313-5813

Secure Text 804-463-5148

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Employment Application

Personal Information
Today's Date*
MM slash DD slash YYYY
Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
E-mail Address*
Primary Phone*
Work Phone
Other Phone
Are you 18 or older?
- Yes
- No
Title of Position Applying For*
Date Available For Work
MM slash DD slash YYYY
Location You Are Able To Work At
- Chesapeake
- Newport News
- Norfolk
- Suffolk
- Virginia Beach
- Williamsburg
- New Town
Are you able to perform the essential functions of the position with or without accommodation?
- Yes
- No
Are you currently employed?
- Yes
- No
If so, may we contact your present employer?
- Yes
- No
How did you hear about the position you are applying for?
- Website
- VEC
- Employment Agency
- Employee
- Advertisement
Employee Name
Check All Days and Hours Available to Work
- Sunday AM
- Sunday PM
- Monday AM
- Monday PM
- Tuesday AM
- Tuesday PM
- Wednesday AM
- Wednesday PM
- Thursday AM
- Thursday PM
- Friday AM
- Friday PM
- Saturday AM
- Saturday PM
Have you been previously interviewed or employed by Pariser Dermatology?
- Yes
- No
If Yes, list date(s) and position(s)
Do you have any relatives currently working for Pariser Dermatology?
- Yes
- No
If Yes, list names and relationship to you
Have you ever been convicted of a crime (misdemeanor or felony)?
(A conviction will not neces sarily disqualify you)
- Yes
- No
If yes, explain where, when, charge, penalty and probation
Employment History
Please provide the following information for your previous three employers, beginning with the most recent:
Employer*
Date Started*
MM slash DD slash YYYY
Date Ended*
Job Title*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Salary Start*
Salary End*
Reason For Leaving*
Job Duties*
Employer*
Date Started*
MM slash DD slash YYYY
Date Ended*
MM slash DD slash YYYY
Job Title*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Salary Start*
Salary End*
Job Duties
Reason For Leaving*
Employer
Date Started
MM slash DD slash YYYY
Date Ended
MM slash DD slash YYYY
Job Title
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Salary Start
Salary End
Job Duties
Reason For Leaving
Education
High School
# Years Completed
Major Area Of Study
Degree/Diploma
College
# Years Completed
Major Area Of Study
Degree/Diploma
Graduate School
# Years Completed
Major Area Of Study
Degree/Diploma
Graduate School
# Years Completed
Major Area Of Study
Degree/Diploma
Military History
Are you a veteran of the U.S. Military?
- Yes
- No
If yes, which branch?*
- Army
- Navy
- Marines
- Air Force
- USCG
Served From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Reserve Status
- Active
- Inactive
References
Please list names of supervisors, ma nagers, or others who can comme nt directly on your abilities
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Relationship / Occupation*
Years Known*
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Relationship / Occupation*
Years Known*
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Relationship / Occupation*
Years Known*
Please list any special training or courses that would enable you to perform the duties of the position you are applying for
APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery. I understand that submission of an application does not guarantee employment. I further understand that, should Pariser Dermatology Specialists extend an offer of employment, that such employment is at will, for no specified duration and may be terminated by either Pariser Dermatology Specialists or myself at any time, with or without cause or notice. I hereby authorize any and all schools, former employers and or references to provide such information to Pariser Dermatology Specialists and I release all parties involved from any and all liability for any and all damage that may result from providing such information. By signing below I acknowledge that I have read, understood and agree to the above statements. Please type your name as an acknowledgement*

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