APPLICATION FOR EMPLOYMENT PAGE 1 OF 2 PERSONAL INFORMATION □ Are you at least 18 years of age? Date: Name: □ Yes No Social Security # Street Address: City, State, ZIP: Home Phone: Cell Phone: List any other names under which you have been employed: Only U.S. citizens and aliens who have a legal right to work in the U.S. are eligible for employment. If you are hired, can you submit documentation verifying your legal right to work in the U.S. and your identity? □ Yes □ No Would you require any special accommodation to perform the job for which you are applying? □ Yes Have you ever been accused of a criminal act, or been convicted or pled guilty to a criminal charge? □ Yes (criminal convictions are not an absolute bar to employment and will only be considered in relation to job requirements) □ No □ No If yes, please explain the circumstances Has any medical license or credential you’ve ever held ever been suspended or revoked? □ Yes □ No Have you taken any illegal drugs in the last 30 days? □ Yes □ No Have you worked at this practice before? □ Yes □ No Are any of your relatives employed by this practice? □ Yes □ No If yes, please explain the circumstances If so, please list them: EDUCATION AND TRAINING Name & Location of High School: Course of Study: Last year Completed: Did you Graduate? □ Yes □ No Grade Point Average: Name & Location of Trade or Technical School: Course of Study: Last year Completed: Did you Graduate? □ Yes □ No Grade Point Average: Name & Location of College or University: Course of Study: Last year Completed: Did you Graduate? □ Yes □ No Grade Point Average: Other Special Training or Skills: C:\Users\Nik\Downloads\Application_for_Employment_24_April_2015 (1).docx Page 1 of 2 APPLICATION FOR EMPLOYMENT PAGE 2 OF 2 EMPLOYMENT INTEREST Position Desired: Desired Schedule: Salary Desired: □ Full-time If required, can you work overtime? □ □ Part Time Yes □ Date Available for Employment: No Can you work weekends? □ Yes □ No EMPLOYMENT HISTORY (please complete the following section even if you are attaching a resume) Employer Name: May we contact? City and State: Job Title: Employed from Supervisor: □ Yes □ No Yes □ No Yes □ No to: Telephone: Key Responsibilities: Reason For Leaving: Employer Name: May we contact? City and State: Job Title: Employed from Supervisor: □ to: Telephone: Key Responsibilities: Reason For Leaving: Employer Name: May we contact? City and State: Job Title: Employed from Supervisor: □ to: Telephone: Key Responsibilities: Reason For Leaving: Do you have any commitments to any of these employers that would limit your activities with this practice? If yes, please explain: □ Yes □ No Explain why you feel you are a good candidate for this position: ____________________________________________________________________________________________________________ I certify that the answers given herein are true and complete and I understand that misrepresentations, omissions of facts or incomplete information requested in this application may remove me from further consideration for employment. Additionally, if employed, any misrepresentation or omission of facts, whenever discovered, is cause for immediate discharge without notice. I grant permission to use any information in this application to verify my statements, and I release all involved parties from any and all liability from the investigation and verification of this information. Signature:________________________________________________ Date: Aesthetic Solutions is an Equal Opportunity Employer and does not discriminate in the hiring process on the basis of gender, religion, race, color, age, national origin, ancestry, disability, sexual orientation or veteran status. C:\Users\Nik\Downloads\Application_for_Employment_24_April_2015 (1).docx Page 2 of 2