Application – Roswell Pain Center

Work Experience (Please begin with your current, or most recent job held):

Company Name:

Name Of Last Supervisor:

Hours received each week?

Address:

Phone Number:

How long did you work there for?

Ending Job Title:

Salary/Hourly Rate?

Reason For Leaving (Please Be Specific):

List any positions you held, duties performed, skills used or learned while working at this company:

Work Experience 2:

Company Name:

Name Of Last Supervisor:

Hours received each week?

Address:

Phone Number:

How long did you work there for?

Ending Job Title:

Salary/Hourly Rate:

Reason For Leaving (Please Be Specific):

List any positions you held, duties performed, skills used or learned while working at this company:

Job Preferences:

Desired Job Position:

Type Of Job:

Date Available To Start?

Resume Upload. Please upload your most recent resume you have available.

Choose a file

Max. size: 32.0 MB

Reference #1:

References Complete Name?

Phone Number?

Relationship To Reference?

Reference #2

References Complete Name?

Phone Number?

Relationship To Reference?

Reference #3

References Complete Name?

Phone Number?

Relationship To Reference?

Terms & Conditions

I agree and understand the following:

1. By signing this application, I authorize EPMed, and any of it’s subsidiaries, to conduct investigations, including verification of my prior employment and education. I authorize all schools I have attended and employers I have worked for to release all relevant information about me. I agree to hold any party, including EPMed, and any of it’s subsidiaries, harmless of any Claims of Liability resulting from these investigations related to the information herein provided.

2. If an offer of employment is made to me, it is conditioned on, among other things: A. My ability to produce documentation establishing both my identity and employment authorization as required by law, and my completion of the employment verification form designated by the Immigration and Naturalization Service; B. My meeting the minimum age requirements of applicable law. (This applies to applicants under the age 18); C. My passing a drug test conducted by an independent laboratory selected by EPMed, or any of it’s subsidiaries. I understand that a negative drug test is a requirement of this offer of employment and hereby agree to waive any and all claims arising from the taking of or results of the drug test.

3. This application, any handbooks, policies, practices, procedures or an offer of employment do not individually or collectively constitute a contract of employment or guarantee of employment for any specific term. Employment with EPMed, and any of it’s subsidiaries, is at-will, which means that my employment can be terminated at any time by EPMed, and of EPMed’s subsidiaries, or by me, without cause or notice.

4. I represent and agree that no obligation owed to another party would prevent me from accepting employment with EPMed, or any of it’s subsidiaries. I further represent that no business or technical information which I know to be confidential, proprietary or private has been submitted in connection with my employment.

By typing my name below I am indicating a full and complete understanding that if I make false statements, fail to disclose information, or fail to provide all the information required, I may be disqualified from being employed or I may be dismissed in the event I become employed by EPMed or any of it’s subsidiaries.

I Agree To The Above Terms & Conditions:

I Agree

Your Complete Name:

Today's Date:

Personal Information

Previous Education

Previous Employers

Interested Job Position

Terms & Conditions

Personal Contact Information:

First Name:

Last Name:

Home Address:

City

ZIP Code:

State

Phone Number:

Contact Email Address:

Additional Background Personal Information:

How did your hear about this job?

Have you ever been employed by this organization in the past?

Are you related to or in any way associated with any current or former employees of El Paso Pain Center, PA or Las Cruces Pain Center or any other of it's affiliates?

Do you have a valid driver's license?

I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States.

Can you submit verification of your legal right to work in the United States? (Proof of eligibility will be required upon employment.)

Will you now or in the future require sponsorship for employment visa status?

If you answered YES to the question above, please explain:

Education:

Do you have a High School Diploma/GED?

Did You Attend A University, Business/Trade College School?

If you answered YES, please tell us the University name or College Attended:

Number Of Years Attended?

Your Major:

Did you complete the course?

Please list any degree, diploma, or certifications received while attending this institution:

Military Experience:

Are you now or have you ever been in the Armed Forces?

Are you currently a member of the National Guard?

Are you the spouse pf a United States Active Duty Military member?

Work Experience (Please begin with your current, or most recent job held):

Company Name:

Name Of Last Supervisor:

Hours received each week?

Address:

Phone Number:

How long did you work there for?

Ending Job Title:

Salary/Hourly Rate?

Reason For Leaving (Please Be Specific):

List any positions you held, duties performed, skills used or learned while working at this company:

Work Experience 2:

Company Name:

Name Of Last Supervisor:

Hours received each week?

Address:

Phone Number:

How long did you work there for?

Ending Job Title:

Salary/Hourly Rate:

Reason For Leaving (Please Be Specific):

List any positions you held, duties performed, skills used or learned while working at this company:

Job Preferences:

Desired Job Position:

Type Of Job:

Date Available To Start?

Resume Upload. Please upload your most recent resume you have available.

Reference #1:

References Complete Name?

Phone Number?

Relationship To Reference?

Reference #2

References Complete Name?

Phone Number?

Relationship To Reference?

Reference #3

References Complete Name?

Phone Number?

Relationship To Reference?

Terms & Conditions

I Agree To The Above Terms & Conditions:

Your Complete Name:

Today's Date: