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First Name  
Middle Name  
Last Name  
Social Security Number  
Street Address / Apt. Number  
City  
State  
Zip  
Home Phone  
Cell Phone  
E-mail Address  
How did you learn about this position? (Be specific with names)    
 
 
 
 
 
 
Have you ever been previously employed by DMOS?  
If yes, list positions held  
Position(s) held Dates
Position(s) held Dates
Have you worked before under another name(s)? (For employment verification)  
If yes, list names  
Position(s) applied for (in order of choice) and Department(s) Area  
1
2
Location Preference  

Date available for employment  
Desired Salary  
Applying for: (check all that apply)  


What is your anticipated length of employment?  
Can you work any hours between 7am to 6pm?  
If no, please explain  
Can you work overtime, including weekends?  
Have you graduated from high school?  
Are you at least 18?  
If no, are you at least 16?  
Education  
Education Entry 1
Type of School
Address of School
Major
# of Years Completed
Graduated
Diploma/Degree Received

Education Entry 2
Type of School
Address of School
Major
# of Years Completed
Graduated
Diploma/Degree Received

Education Entry 3
Type of School
Address of School
Major
# of Years Completed
Graduated
Diploma/Degree Received
Office Skills: (check all that apply)  
 
 
 
Please list any additional experience, skills, and qualifications which may relate to the job for which you are applying  
Consistent attendance and punctuality are essential requirements of every job with this company. Is there anything which would interfere with your regular attendance and punctuality if you are offered a job with this company  
If yes, please explain  
Professional Licenses and/or Certificates  
Professional License/Certificate 1
Type
License/Cert. No.
State Issued
Expiration Date
Name

Professional License/Certificate 2
Type
License/Cert. No.
State Issued
Expiration Date
Name
Employment  

Give a complete record of all employment and reasons for periods unemployed. Include volunteer work, military service, etc. Start with present or most recent employer.

Employment 1
Company Name
Company Address
Company Telephone
Status
Employed From
(month & year)
Employed To
(month & year)
Name and Title of Immediate Supervisor
Starting Hourly Pay/Salary
Ending Hourly Pay/Salary
Position Held and Describe Your Duties
Reason for Leaving
(please explain)
Explain any period/gaps between jobs
May we contact your employer

Employment 2
Company Name
Company Address
Company Telephone
Status
Employed From
(month & year)
Employed To
(month & year)
Name and Title of Immediate Supervisor
Starting Hourly Pay/Salary
Ending Hourly Pay/Salary
Position Held and Describe Your Duties
Reason for Leaving
(please explain)
Explain any period/gaps between jobs
May we contact your employer

Employment 3
Company Name
Company Address
Company Telephone
Status
Employed From
(month & year)
Employed To
(month & year)
Name and Title of Immediate Supervisor
Starting Hourly Pay/Salary
Ending Hourly Pay/Salary
Position Held and Describe Your Duties
Reason for Leaving
(please explain)
Explain any period/gaps between jobs
May we contact your employer

Employment 4
Company Name
Company Address
Company Telephone
Status
Employed From
(month & year)
Employed To
(month & year)
Name and Title of Immediate Supervisor
Starting Hourly Pay/Salary
Ending Hourly Pay/Salary
Position Held and Describe Your Duties
Reason for Leaving
(please explain)
Explain any period/gaps between jobs
May we contact your employer
Business References  

Give name(s) of person(s) familiar with your current abilities who we may contact for a reference. Please do not list relatives, friends or co-workers. We will assume we have your permission to contact these people unless you indicate to the contrary.)

Business Reference 1
Name
Relationship to Applicant/Title
Organization
Years Known
Home Phone
Work Phone
Cell Phone
Address

Business Reference 2
Name
Relationship to Applicant/Title
Organization
Years Known
Home Phone
Work Phone
Cell Phone
Address
Have you ever been discharged from any employment or been asked to resign?  
If yes, list employer, dates, reason and explanation  
A conviction record will not necessarily disqualify an applicant from employment. The circumstances of a conviction will be considered in relation to the nature and duties of the job for which you apply. Have you ever been convicted of a serious misdemeanor or felony?  
If yes, please explain – give dates including lapse of time between convictions and current job selection process  
Only US citizens or aliens who have a legal right to work in the United States are eligible for employment. Are you a citizen of the United States or specifically authorized to be employed in the United States?  
Can you, upon employment provide genuine documentation establishing your identity and eligibility to be legally employed in the U.S.?  
Please Note   Each employee is required to comply with staffing assignments. As work changes occur within departments, employees may be required to change shifts and/or days worked temporarily, or on a regular basis.
Are you able to perform the essential functions of the job for which you are applying, either with/without reasonable accommodations?
(If you have any question as to what functions are applicable to the position for which you are applying, please ask the interviewer before you answer the questions.) 		 
If no, describe the functions that cannot be performed.  
Signature  

By signing below, I certify that the answers and information given by me are true, accurate, and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of fact on this application (or any other accompanying or required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.

I certify as an applicant that my application will be disqualified is any information is provided beyond that which is sought.

I authorize the employer to investigate all statements contained in this application for employment. I release the employer from all liability for acts performed in good faith and without malice in connection with evaluation of my application.

I authorize my prior employers, references, and others with information regarding my work, educational history or my character, to provide the employer with all information requested and to cooperate fully with the investigation of my character and qualifications. I also release those employers, references and others from all liability for providing information in good faith and without malice.

I understand that this application is not a contract of employment. If hired, my employment and compensation can be terminated at will, with or without a showing of cause, and with or without notice by either myself or my employer. I agree that if employed, I will abide by all policies, procedures, rules and regulations established by Des Moines Orthopaedic Surgeons, P.C.

I also understand that if I am offered employment, the offer is conditioned upon receipt of satisfactory employment references.

I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me.

Applicant's Signature  
Date  
   

Des Moines Orthopaedic Surgeons, P.C. (DMOS) is an Equal Opportunity Employer and will not discriminate or tolerate discrimination against any employee or applicant in any manner prohibited by law.