Employment Application Step 1 of 9 11% Name First Last Business PhoneHome PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Referred By Employment DesiredPosition Applying ForAre you applying for:Regular full-time workYesNoRegular part-time workYesNoWhat days and hours are you available for work?Are you available for work on weekends?YesNoWould you be available to work overtime, if necessary?YesNoIf hired, on what date can you start work?Salary desired:Which of the following locations would you be willing to work at on a regular basis? Bakersfield Downey Fresno Glendale Long Beach Los Angeles (Downtown) Los Angeles (West) Mission Hills Modesto Montclair Oakland Riverside Sacramento San Bernardino San Diego (Downtown) San Diego (North) Santa Ana Temecula Torrance West Covina Personal InformationHave you ever applied to or worked for this company before?YesNoIf yes, when?Do you have any friends or relatives working for the company?YesNoIf yes, state name(s) and relationship? Why are you applying for work at this company? If hired, would you have a reliable means of transportation to and from work?YesNoAre you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.)YesNoIf hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?YesNoAre you able to perform the essential functions of the job for which you are applying?YesNoIf no, describe the functions that cannot be performed Have you are been convicted of a criminal offense (felony or serious misdemeanor)?YesNoIf yes, state nature of the crime(s), when and where convicted and disposition of the case Are you currently employed?YesNoIf so, may we contract your current employer?YesNoDo you speak, write or understand any foreign languages?YesNoIf yes, which language(s)?Do you have any other experience, training, qualifications or skill, which you feel make you especially, suited or work at this company? If so, please explain Answer the following question if you are applying for a professional positionAre you licensed/certified for the job applied for?YesNoName of license/certificationIssuing stateLicense/certification numberHas your license/certification ever been revoked or suspended?YesNoIf yes, state reason(s), date of revocation or suspension and date of re-instatementTell us about yourselfPlease provide a written paragraph explaining why you feel you would be an excellent addition to the FPA medical team. What are your future goals? What is the most important thing to YOU in relation to your job? Why did you leave your previous job? Education / Professional TrainingHigh SchoolName and Address Number of years completedDid you Graduate?YesNoDegree / Diploma YearEducation / Professional TrainingName and Address Number of years completedDid you Graduate?YesNoDegree / Diploma YearVocational / BusinessName and Address Number of years completedDid you Graduate?YesNoDegree / Diploma YearHealthcareName and Address Number of years completedDid you Graduate?YesNoDegree / Diploma Year Employment HistoryMost Recent EmploymentDates of EmploymentName of EmployerType of BusinessPosition HeldPrevious EmploymentDates of EmploymentName of EmployerType of BusinessPosition HeldPrevious EmploymentDates of EmploymentName of EmployerType of BusinessPosition Held Military ServiceHave you obtained any special skills or abilities as the result of service in the military?YesNoIf so, describe Personal / Professional ReferencesReferenceNameAddressCityStateZipOccupationPhoneNumber of years acquaintedReferenceNameAddressCityStateZipOccupationPhoneNumber of years acquaintedReferenceNameAddressCityStateZipOccupationPhoneNumber of years acquainted I hereby certify that I have not knowingly withheld any information that might adversely affect my chance for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed regardless of the time elapsed before discovery.* Yes No I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.* Yes No I hereby agree to submit to binding arbitration all disputes and claims arising out of the submission of this application. I agree that such arbitration shall be conducted under the commercial rules of the American Arbitration Association and shall take place in the Los Angeles Office of the American Arbitration Association. I hereby waive my right to a jury trial or trail by a judge sitting without a jury and agree that arbitration as described in this paragraph shall be utilized to settle any disputes that arise in lieu of any court proceedings.* Yes No I understand that nothing contained in the application, or conveyed during any interview, which may be granted, or during my employment, if hired, is intended to create an employment contract between me and the company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s designated representative.* Yes No Date* Applicant’s Signature* First Last PhoneThis field is for validation purposes and should be left unchanged.