Date(Required)

Position Applying For?(Required)

Name(Required)

First Last

Phone(Required)

Secondary Phone

Address(Required)

Street Address Address Line 2 City State ZIP Code

Do you have the legal right to work in the U.S.? If yes, proof will be required after employment.(Required)

Are you at least 18? If no, please show work permit.(Required)

Yes

Experience & Skills – Office Skills

Typing (words per minute)(Required)

Yes

Typing Skill Level(Required)

Fair

Good

Excellent

Computer(Required)

Yes

Computer Skill Level(Required)

Fair

Good

Excellent

Treatment Presentation(Required)

Yes

Treatment Presentation Skill Level(Required)

Fair

Good

Excellent

Fee Presentation(Required)

Yes

Fee Presentation Skill Level(Required)

Fair

Good

Excellent

Account Collections(Required)

Yes

Account Collections Skill Level(Required)

Fair

Good

Excellent

Appointment Scheduling(Required)

Yes

Appointment Scheduling Skill Level(Required)

Fair

Good

Excellent

Multi-Function Phones(Required)

Yes

Multi-Function Phones Skill Level(Required)

Fair

Good

Excellent

Cash Register(Required)

Yes

Cash Register Skill Level(Required)

Fair

Good

Excellent

Phone Etiquette(Required)

Yes

Phone Etiquette Skill Level(Required)

Fair

Good

Excellent

Other skill?(Required)

Yes

What is the other skill:(Required)

Other Skill Level(Required)

Fair

Good

Excellent

Experience & Skills – Clinical Skills

Assisting Surgeries(Required)

Yes

Assisting Surgeries Skill Level(Required)

Fair

Good

Excellent

Pack Prep(Required)

Yes

Pack Prep Skill Level(Required)

Fair

Good

Excellent

Urinalysis(Required)

Yes

Urinalysis Skill Level(Required)

Fair

Good

Excellent

Blood Analysis(Required)

Yes

Blood Analysis Skill Level(Required)

Fair

Good

Excellent

Fecal Analysis(Required)

Yes

Fecal Analysis Skill Level(Required)

Fair

Good

Excellent

Take & Develop X-Rays(Required)

Yes

Take & Develop X-Rays Skill Level(Required)

Fair

Good

Excellent

Injections IV, IM, etc.(Required)

Yes

Injections IV, IM, etc.(Required)

Fair

Good

Excellent

Anesthesia(Required)

Yes

Anesthesia Skill Level(Required)

Fair

Good

Excellent

OSHA & Safety Reg.'s(Required)

Yes

OSHA & Safety Reg.'s Skill Level(Required)

Fair

Good

Excellent

Other Skill?(Required)

Yes

What is the other skill:(Required)

Other Skill Level(Required)

Fair

Good

Excellent

Education

High School

Name of School(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Did you graduate?(Required)

Yes

Number of years attended:(Required)

Course or major?(Required)

Add University or College?(Required)

Yes

University or College

Name of School(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Did you graduate?(Required)

Yes

Number of years attended:(Required)

Course or major?(Required)

Add Special Training or Courses?(Required)

Yes

Special Training or Courses

Name of School(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Did you graduate?(Required)

Yes

Number of years attended:(Required)

Course or major?(Required)

General Information

Can you meet the general requirements of the job?(Required)

Yes

Do you have the required license(s) to perform the job?(Required)

Yes

I can work:(Required)

Days

Evenings

From:(Required)

To:(Required)

Number of days per week:(Required)

Number of hours per week:(Required)

Select the days of the week you will NOT be available for work:(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Date available to start?(Required)

Can your vacation be arranged at practice convenience?(Required)

Yes

Please explain:(Required)

Salary requirement:(Required)

Per hour:(Required)

Benefits required?(Required)

Yes

Employment History/Work Experience

Please include all employment, self-employment & unemployment. If additional pages are needed, please attach. Do not substitute with a resume. List present or most recent position first.

Name of employer(Required)

Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Employed From:(Required)
MM slash DD slash YYYY

Employed To:(Required)
MM slash DD slash YYYY

Position(s) Held:(Required)

Supervisor Name(Required)
First Last

Supervisor Title:(Required)

Average # of hours worked per week:(Required)

Rate of pay (start)(Required)

Rate of pay (ending)(Required)

Your Last Name at Time of Employment(Required)

Describe your duties:(Required)

May we contact this employer?(Required)

Yes

No

Give specific reasons for leaving:(Required)

Add another employer?(Required)

Yes

No

Name of employer(Required)

Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Employed From:(Required)
MM slash DD slash YYYY

Employed To:(Required)
MM slash DD slash YYYY

Position(s) Held:(Required)

Supervisor Name(Required)
First Last

Average # of hours worked per week:(Required)

Rate of pay (start)(Required)

Rate of pay (ending)(Required)

Your Last Name at Time of Employment(Required)

Describe your duties:(Required)

May we contact this employer?(Required)

Yes

No

Give specific reasons for leaving:(Required)

Add a third employer?(Required)

Yes

No

Name of employer(Required)

Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Employed From:(Required)
MM slash DD slash YYYY

Employed To:(Required)
MM slash DD slash YYYY

Position(s) Held:(Required)

Supervisor Name(Required)
First Last

Average # of hours worked per week:(Required)

Rate of pay (start)(Required)

Rate of pay (ending)(Required)

Your Last Name at Time of Employment(Required)

Describe your duties:(Required)

May we contact this employer?(Required)

Yes

No

Give specific reasons for leaving:(Required)

References

List three personal references not related to you.

Name(Required)
First Last

Phone(Required)

Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name(Required)
First Last

Phone(Required)

Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name(Required)
First Last

Phone(Required)

Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bremen Animal Clinic is an equal opportunity employer

General Agreement

I understand that all offers of employment are conditioned on receipt of satisfactory responses to reference requests and the provision of satisfactory proof of an applicant’s identity and legal authority to work in the United States. In consideration of my employment, I agree to conform to the rules and standards of the practice, as amended from time to time at the employer’s discretion.

Authorization To Check References

I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the information checked unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals whom the practice may contact, to provide any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from all liability for any damages that may result from furnishing the practice with such information as well as from the use or disclosure of such information by the employer or any of its agents, employees or representatives. I understand that any misrepresentation, falsification or omission of material information on this application may result in my failure to receive an offer, or, if I am hired, in my dismissal from employment.

Employment Relationship

If employed, I understand that the employment with the practice is not for a specified term and can be terminated “At Will,” with or without cause at any time, either at the option of the employee or the employer. No employee or representative of the practice, other than its owner, has the authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing. Further the employer may not alter the “At-Will” nature of the employment relationship unless it is done specifically and in writing that is signed by the owner. I agree that this constitutes a final and fully binding agreement with respect to the “At-Will” nature of my employment relationship. There are no oral or collateral agreements regarding this issue.

Date(Required)
MM slash DD slash YYYY

Signature(Required)

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