Employment Application

Please read before completing this application

It is the policy of Blue Springs Surgery Center (the Company) to provide equal employment opportunity to all qualified persons without regard to race, color, sex/gender, age, religious beliefs, marital status, pregnancy, national origin, physical/mental disabilities, genetic information, sexual orientation, gender identity, gender expression or any other characteristic protected by law.

This application will be given every consideration, but its receipt does not imply that there are any positions open, or that an applicant will be employed. Only applicants meeting the minimum requirements for a position as determined by the Company will be considered for employment. Should more than one qualified person make application, the Company reserves the right to select the applicant, in its opinion, with the best qualifications.

A clear understanding of your background and work history will aid us in assessing your qualifications. An incomplete application will be rejected.


Full-Time
Part-Time
Per Diem
Are you able to perform all essential functions of the job?
Yes
No
Are you over the age of 18?
Yes
No
(If no, you may be required to provide authorization to work.)

Education

High School
College
Other (Specify)
With what software are you proficient?
Shift Availability (check one)
Licensed As

Have any professional license privileges ever been suspended or revoked?

If so why, when and where?

Employment Record

Starting with Present or Most Recent, list all previous employers and supply all requested information. Include self- employment, summer, part-time jobs and any period of unemployment. If you need more space, please continue on a separate sheet. Please indicate any change of name or assumed name used in work experiences. Any gaps in information will cause this to be rejected as an incomplete application. We do NOT accept “See Resume”.

1.

Description of duties

Reason for leaving


2.

Description of duties

Reason for leaving


3.

Description of duties

Reason for leaving


4.

Description of duties

Reason for leaving

Did you provide full details of employment history including months and years of employment, supervisor names, phone numbers, and specify reasons for leaving? If not, please do so.


If you are now employed, may we contact your employer?
Are you now or have you ever been employed by Blue Springs Surgery Center?

If so, when and where?

If presently employed, why do you desire to change your position?

Professional References

Name of three persons, not relatives, who may be contacted at the present time.


I authorize investigation of all statements contained in this application (if I am considered for employment) and hereby authorize previous employers, professional references named, or any other person or persons to whom the company may refer, to give any and all information regarding my background, if requested.

In the event of my employment to a position at Blue Springs Surgery Center., I will comply with all rules and regulations as set forth in Blue Springs Surgery Center’s policy manual or other communications distributed to employees. If a job offer is made, I agree to complete a health evaluation which may include a physical examination by a doctor selected by Blue Springs Surgery Center. (at Blue Springs Surgery Center’s expense). Additionally, I authorize Blue Springs Surgery Center to supply my employment record in whole or in part to only those agencies having legal and proper interest. Also, in the event of my employment by Blue Springs Surgery Center, I grant permission to use my photograph in connection with its advertising and public relations programs.

I hereby certify that I have read all the above statements and understand the same and that all statements made by me are true and accurate to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that any false statements or material omissions may be grounds for refusal to hire, or for immediate dismissal. I certify that I am legally authorized to work in the United States.

Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Blue Springs Surgery Center (the facility) and myself for either employment or the providing of any benefit. I further understand that if I am employed by Blue Springs Surgery Center (employer) that my employment will be for no definite term (“at-will”) and that either I, or the employer, will have the right to terminate the employment relationship at any time, with or without cause. I also understand that this status can only be altered by a written contract of employment which is specific to all material terms and is signed by me and an officer of the employer.

I understand that as a condition to this application and any employment with Blue Springs Surgery Center, I may be required to submit to testing for the presence of drugs and/or alcohol. I hereby consent to such testing. I further acknowledge that no promises regarding employment have been made to me, and that no promise or guarantee is binding upon employer unless made in a written contract of employment as described above.

I have read and agree to all of the above statements.



Blue Spring Surgery Center’s patients may request a more personalized estimate of charges and other information from our facility and other health care providers. Always contact your health care practitioner to insure that they participate within our network.

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