Application for Employment

The New Hartford Animal Hospital is an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including age, sex, color, race, creed, national origin, religious persuasion, marital status, political belief, or disability. I understand that the omission of facts or incomplete information in this application is grounds for immediate dismissal at any time without any previous notice.

I. Personal Information (please print)

Name: Last First Middle Telephone

Present Address City State Zip SS#

Position Applied For: How did you learn of us?

1. If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes / No

2. Have you ever filed an application with us before? Yes / No If yes, when

3. Have you ever been employed with us before? Yes / No If Yes, when

4. Are you currently employed? Yes / No

5. May we contact your current employer? Yes / No

6. Are you able to perform the essential functions of this job for which you are applying, with or without reasonable accommodation? Yes / No

7. Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? Yes / No

8. Are you legally authorized to work in the U.S.? Yes / No

(You will be required to produce supporting documentation within 3 days of start date.)

9. Have you ever been convicted of any criminal offense? Yes / No

If Yes, please list convictions:

II. Work Availability and Salary Requirements

1. If your application receives favorable consideration, when will you be available to begin work?

2. Do you have any objections to working overtime? Yes / No

3. Can you work overtime without prior notice? Yes / No

4. Can you travel if required by this position? Yes / No

5. Are you currently on layoff status and subject to recall? Yes / No

6. Are you available to work: Full-time / Part-time / Shift work / Temporary

7. If your application receives favorable consideration, what salary/hourly rate would you require?

III. References (Please do not include relatives or former employers.)

1. Name Telephone Years Known Occupation

2. Name Telephone Years Known Occupation

3. Name Telephone Years Known Occupation

IV. Education History

The absence of any degree of formal education will not necessarily bar you from consideration of employment, unless it is necessary for the position applied for.

Elem./Jr. High School Name Location Years Completed

High School Name Location Years Completed

College Name Location Years Completed

V. Employment Record (Please include all employment for the last three years)

current or most recent employer

Company Name Position Held Wage/Salary

Address Telephone Dates Employed

Manager/Supervisor Reason for leaving

Company Name Position Held Wage/Salary

Address Telephone Dates Employed

Manager/Supervisor Reason for leaving

Company Name Position Held Wage/Salary

Address Telephone Dates Employed

Manager/Supervisor Reason for leaving

OMISSION OR FALSIFICATION OF THE ABOVE, IS GROUNDS FOR IMMEDIATE DISMISSAL

Background Information Authorization and General Release

I, the undersigned applicant in connection with this application, authorizes all corporations, companies, educational institutions, persons, law enforcement agencies, military services, and former employers to release information they may have about me to New Hartford Animal Hospital or it’s agents and releases them from any liability or responsibility from doing so. No credit agency check or investigative consumer report will be done without a specific, separate, written consent for such agreed to by the applicant.

Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity (valid driver’s license, birth certificate, Green Card, etc.) within three days of being hired. Failure to submit such proof within the required time shall result in immediate employment termination.

by clicking submit you are hereby submitting your digital signature