Pariser Dermatology

Job Openings

Medical Assistant/Scribe

Newport News, Norfolk, Suffolk, Williamsburg

Posted 3 years ago

Medical Assistant (Special Surgery Department)

Newport News, Norfolk

Posted 3 years ago

Surgery Assistant/Scribe – (Suffolk/Williamsburg)

Suffolk, Williamsburg

Posted 3 years ago

Employment Application

"*" indicates required fields

Personal Information

Today's Date*

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

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?

Employee Name

Check All Days and Hours Available to Work

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:

Current Employer*

Date Started*

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*

Date Ended*

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

Date Ended

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?

Served From

To

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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