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Florida Orthopaedic Institute and its Affiliates are an equal opportunity employer and will consider all applicants for all positions equally without regard to their race, sex, age, color, religion, national origin, veteran status, or any disability as provided in the Americans with Disabilities Act.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered.

Personal:

Name: Last First Middle Home Phone: (xxx)-xxx-xxxx

Present Address: Street Address City State Zip

Are you over 18? SSN: xxx-xx-xxxx

Have you ever been convicted of any crime (excluding minor traffic violations) including DWI or DUI?

If yes, state the offsense, location, date, and disposition:

Do you have the ability to work overtime if required by the job for which you are applying? Do you have the ability to travel if required by the job for which you are applying?

If no, please explain:

Would you be willng and able to relocate?

Employment Desired:

I am seeking:

Full Time Part Time Temporary or summer employment

Position applied for: Salary desired Date available to start:

Have you ever applied to our company before? Have you worked for our company before?

If your answer to either of the above questions is Yes, state when and where you applied and/or worked

How did you learn of our company and/or position?

Are you now, or do you expect to be, working in any other business or job?

Are there any days or hours you would be unable or unwilling to work?

If yes, please specify those days or hours you would be unable or unwilling to work

Education:

Name, Address, and Location	Dates	Graduate?	Courses Studied
High School
College	From To
Trade School	From To

If you did not graduate, why did you leave high school or college?

Are you planning to pursue further studies?

If so, when, where, and what courses?

List any scholastic honors, offices held, and activites involved in during high school and college

List and describe any other school or specialized training

Military:

Have you ever served in the military?

Service Branch	Date Entered
Date Separated	Final Rank

Capability / Reliability:

Would you be willing and able to perform all of the tasks required by the job you are applying for?

If not, explain which tasks

Have you filed any type of fraudulent claim against any of your present of past employers?

If yes, explain

Will you abide by all company policies and procedures?

Have you ever been disciplined for violating company safety rules or regulations?

If yes, please explain

Would you be willing and able to report to work on time every day on a regular and consistent basis?

If no, please explain

Work History:

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references.

PLEASE GIVE MONTH AND YEAR DO NOT REFERENCE YOUR RESUME

Employer #1

Name of Employer, Address, City, State, Zip Code
Telephone (xxx)-xxx-xxxx	Nature of Business

Name and Title of Last Supervisor	Dates Employed		Pay
	From: Month Year	To: Month Year	Starting $ Ending $

Duties

Reason for Leaving

Employer #2

Name of Employer, Address, City, State, Zip Code
Telephone (xxx)-xxx-xxxx	Nature of Business

Name and Title of Last Supervisor	Dates Employed		Pay
	From: Month Year	To: Month Year	Starting $ Ending $

Duties

Reason for Leaving

Employer #3

Name of Employer, Address, City, State, Zip Code
Telephone (xxx)-xxx-xxxx	Nature of Business

Name and Title of Last Supervisor	Dates Employed		Pay
	From: Month Year	To: Month Year	Starting $ Ending $

Duties

Reason for Leaving

Employer #4

Name of Employer, Address, City, State, Zip Code
Telephone (xxx)-xxx-xxxx	Nature of Business

Name and Title of Last Supervisor	Dates Employed		Pay
	From: Month Year	To: Month Year	Starting $ Ending $

Duties

Reason for Leaving

Supplemental Employment Information:

If you worked in any of your previous positions under another name, please give that name(s)

Are you presently employed?

If yes, may we contact your present employer?

Have you ever been fired or asked to resign from a job?

If yes, please explain

Special Skills:

Do you type?

Words Per Minute

Have you had any computer or word processing experience or training?

If yes, please describe

What languages do you speak fluently?

Use the space below to describe why you are interested in working for our company and to list those skills and abilities which you feel particularly qualify you for a position with us.

References:

Give three references, not relatives or former employers.

Name	Address	Phone	Occupation
#1
#2
#3

Resume:

Upload Your Resume

Email:

Email Address

Affidavit:

I agree to the following statement...

I certify that my answers to the foregoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading, or otherwise incorrect statements made on this application form or during any interviews may be grounds for my immediate discharge.

I hereby authorize Florida Orthopaedic Institute and its affiliates to contact any company or individual it deems appropriate to investigate my employment history, character, and qualifications, and I give my full and complete consent to their revealing any and all information they wish as a result of this investigation. In addition, I hereby waive my right to bring any cause of action against these individuals for defamation, invasion of privacy, or any other reason because of their statements.

I agree that if I am employed, I will abide by all the rules and regulations of the company. I understand that the taking of drug and alcohol tests, when given pursuant to company policy, are a condition of continued employment and refusal to take such tests when asked will be grounds for my immediate termination. I further understand that nobody in the Company is authorized to enter into any written or verbal employment contracts with me for any definite period of time without the express written consent of the President of the Company. I also understand that my employment is "at-will" and may be terminated by myself or by Florida Orthopaedic Institute at any time for any reason, or no reason at all, with or without prior notice.

Type your initials to indicate you agree to the following statement