Please fill out the application form below if you’re interested in becoming part of our team of qualified individuals. If you have any problems or questions, please contact us.

Application for Employment


Position Applied For:
Your Email Address (required):

Personal Data - Part One


First Name:
Last Name:
Middle Initial:
Maiden Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Salary Desired:
Time Preference:
Days Available: MondayTuesdayWednesdayThurdayFridaySaturdaySunday
Hours Available:
Willing to Work Overtime:
Geographic Preference:

Personal Data - Part Two


Please answer Yes or No

Are you legally authorized to work in the United States? YesNo
Are you over the age of 18? YesNo
Are you a previous employee of Advanced Urology Institute? YesNo
Do you have any relatives presently working for Advanced Urology Institute? YesNo
Have you ever used illegal drugs? YesNo
Have you ever been convicted of, or plead Noto Contrende to a Felony Crime? YesNo
If answered "yes" to Felony Crime question above, please describe in full:

Work History - Most Recent Position


Start Date:
End Date:
Job Title:
Starting Salary:
Ending Salary:
Hours per Week:
Name and Address of Employer:
Reasons for Leaving:
Name of Supervisor:
May We Contact This Employer? YesNo
Description of Duties and Responsibilities:

Work History - Second Most Recent Position


Start Date:
End Date:
Job Title:
Starting Salary:
Ending Salary:
Hours per Week:
Name and Address of Employer:
Reasons for Leaving:
Name of Supervisor:
May We Contact This Employer? YesNo
Description of Duties and Responsibilities

Work History - Third Most Recent Position


Start Date:
End Date:
Job Title:
Starting Salary:
Ending Salary:
Hours per Week:
Name and Address of Employer:
Reasons for Leaving:
Name of Supervisor:
May We Contact This Employer? YesNo
Description of Duties and Responsibilities:

Skills and Qualifications


List special qualifications and skills you possess regarding the position for which you are submitting this application.

List any professional License or Certificates

Name State Licensing Authority Years Expiration Date
Skill 1
Skill 2
Skill 3

References


List 3 (three) business references (Do not list any relatives or personal friends)

Name Telephone Address Relationship
Reference 1
Reference 2
Reference 3

Read Carefully Before Submitting This Application

As an applicant with Atlantic Urological Associates, I hereby state that all information set forth in my application are true and complete statements of fact. I understand and agree that if employed, false statements, omissions or misleading statements listed on this application, regardless of the time they are discovered, shall be considered sufficient cause for dismissal. Additionally, by my submission of this application I authorize the release of information regarding my education, background, and my work history. I also discharge, with my signature shown below, any and all liability of those who release such information. Atlantic Urological Associates shall not be held liable in any respects if my employment is terminated because of such false statements, omissions or misleading statements.
Initials: