Position You are Applying For:  Clinic Staff | If you would like to download the application and mail it to us; you may click here to download.
PERSONAL DATA Each applicable field in this section must be completed
 Per
EDUCATION
ADVANCED EDUCATION (If Applicable) Each field in these sections must be completed, or we cannot accept your education record(s)
MILITARY RECORD
EMPLOYMENT HISTORY Each field in these sections must be completed, or we cannot accept your Employment History record(s)
CURRENT/ MOST RECENT EMPLOYMENT
STARTED:
ENDED:
$ Per:
1. PREVIOUS EMPLOYMENT
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ENDED:
$ Per:
2. PREVIOUS EMPLOYMENT
STARTED:
ENDED:
$ Per:
3. PREVIOUS EMPLOYMENT
STARTED:
ENDED:
$ Per:
4. PREVIOUS EMPLOYMENT
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ENDED:
$ Per:
LICENSURE / SKILLS AND TRAINING / QUALIFICATIONS Please list your current professional or technical license, and/or certificates, if applicable
PROFESSIONAL OR TECHNICAL REGISTRATION, LICENSE AND/OR CERTIFICATION
MISCELLANEOUS INFORMATION/AFFIDAVIT Please read the information below and answer all of the questions carefully. Attach additional sheets if necessary.
PROFESSIONAL REFERENCES:
Name Relationship to Applicant Name of organization where individual knew your work performance Address Telephone
AFFIDAVIT

I certify that the answers given by me to the foregoing questions and statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentations of facts called for in this application or during the interview may result in rejection of my application or immediate discharge at any time during my employment. I understand that employment is contingent upon, but not limited to receipt of satisfactory references, an employment physical, license verification, criminal history, motor vehicle driving records and proof of identity and authorization to work in the United States.

In consideration of my employment, I agree to conform to the rules and regulations for TPG, and I understand that my employment with TPG is of an "at will" nature, and I understand that this means that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time at the option of either TPG or myself. I understand that no representative of TPG has any authority to enter into any agreement, promise or contract for employment of me for any specified period of time. I further understand that no representative of TPG has any authority to make any agreement, promise or contract contrary to the foregoing.

Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a consumer report may be made in connection with your application for employment.

I understand that the use of illegal drugs is prohibited during employment. I consent to submit to a Drug Screening Test for illegal drugs, including Urine Screening Test, to determine the presence of illegal drugs.

12/14/2019
AN EQUAL OPPORTUNITY EMPLOYER