Employment Application

(866)872-8799

  
 
Midtown Surgical Associates P. O. Box 79105 Atlanta, GA 30357  
Personal Information: ( * indicates required information)
Position Applied for:
* Name:
First:
Middle Initial:
Last:
* Social Security Number:
* Present Address:
Street:
 
City:
State:
Zip:
* Telephone (enter at least one):
Home:
Work:
Cell:
* Email address:
* Date of Birth:
Are you a U.S. Citizen ? Yes No

If not, can you produce evidence that you have a legal right to remain and work in the U.S.?

 Yes No
Are you willing to take physical exams as required by MSA? Yes No
Have you ever been convicted of a Felony? (NOTE: A conviction will not automatically exclude an applicant, but all circumstances will be considered.) Yes No
If yes, explain:
Have you ever been employed by MSA? Yes No
If yes, name at that time:
If yes, give department and dates of employment:
Do you have any relatives working at MSA? Yes No
If yes, give name and relationship:
Referred to MSA by:
Work Availability: Full Time
Part Time
Weekends Only
Summer Only
Temporary
Shift Preference: Any Shift
Day
Evening Shift
Night Shift
Other Shifts
----
Date Available for work:
   
Special Skills: (check all you can perform)
Surgical Skills:

General
OB/GYN
Orthopaedic
Plastic
EENT
Urology/Renal
Organ Transplant
Cardio Vascular/Thoracic
Neurosurgery General

Office Skills: Typing
---- WPM:
PC
Word Perfect
Word
Lotus
Excel
Dictaphone
Other
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Military Status:
Present Status: (discharged, reserve or draft classification)
Dates of service:

From:
To:

Rank or Rating:
Type of discharge:
Specialty and responsibilities:
   
Professional Registration: (for position requiring registration and license only)
State Date: Registry No.
State Date: License No.
   
Education:
Name and address of School, College, Graduate Schools, Business Schools and School of Nursing From To Diploma and Degree Major Subject and Special Courses taken Other Courses taken that would relate to the position you are applying for
Mo. Yr. Mo. Yr.
   
Employment Records:
Name and address of present and former employers From To Position and Duties Salary Reason for leaving
Mo. Yr. Mo. Yr.
List any period unemployed:
   
Personal References: (Current or Former Supervisors)
May we contact your present employer? Yes No
Title Company City, State Daytime phone No. (if known)
   

MSA is an equal opportunity employer. No questions on this application is asked in order to limit or exclude an applicant's consideration for employment for reasons prescribed by law. I understand that as part of normal procedure for processing employment applications and employment requests, a routine inquiry may be made concerning information on character, general reputation, personal characteristics and mode of living. I understand that a satisfactory CRIMINAL RECORD CHECK is required as condition of employment. I authorize such obligation and if one is made, acknowledge that the information is available upon request. I also authorize Midtown Surgical to contact references and former employers, as well as authorize the release of any medical records or information in connection with my physical condition in the present.

Pursuant to the Immigration Reform and Control act of 1886, all applicants upon being made an offer of employment, must provide documents, which are specified by the federal government establishing their identity and authorization for employment in the United States. These documents must be produced no less then seventy-two hours after commencent of employment. You will also be required to sign a Form I-9 (issued be the Federal Government) verifying under oath, your employment authorization.

The facts set forth above in my application are true and complete. I understand that if I am employed, false statements on this application should be considered sufficient cause for dismissal. I further agree that the use of this application does not indicate that there are any positions open and does not in any way obligate this organization. If I am employed, I agree to abide by the rules and regulations of the organization currently in effect and as amended. I also understand that my employment and compensation may be terminated with or without cause or notice at any time by organization or myself. No policy, practice, manual or handbook of the Agency is intended to create a contractual agreement, and are subject to change without notice.