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Medical Associates of Erie Employment Application
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1
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5
20%
Personal Data
Legal Name
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Have you ever interviewed with MAE or any of its affliates (LECOM, Millcreek Community Hospital, LECOM Wellness Center, LECOM Senior Living Center)?
*
Yes
No
If yes, please list the affiliate, job title and date.
Have you ever been employed with MAE or any of its affliates (LECOM, Millcreek Community Hospital, LECOM Wellness Center, LECOM Senior Living Center)?
*
Yes
No
If yes, please list the affiliate, job title and date.
Do you have any relatives employed with MAE or any of its affliates (LECOM, Millcreek Community Hospital, LECOM Wellness Center, LECOM Senior Living Center)?
*
Yes
No
If yes, please list their name, who they are employed by and job title.
Are you a U.S. citizen?
*
Yes
No
Are you at least 18 years old?
*
Yes
No
Are you at least 16 years old?
*
Yes
No
If you are under 18, do you have a valid work permit?
*
Yes
No
Are you currently employed?
*
Yes
No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?
*
Proof of immigration status will be required upon employment.
Yes
No
How did you learn about this job opening?
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Friend
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Other
Background
May we contact your current employer for references
*
Yes
No
Will you be able to perform the essential job functions for the position you are applying for with our without reasonable accommodations?
*
Yes
No
Have you ever been convicted of a crime, excluding misdemeanors and summary offenses, which have not been annulled, expunged or sealed by court?
*
Yes*
No
*Answering yes will not necessarily disqualify you from consideration for employment. Please Provide Details of the conviction(s) including date, conviction, and in what state it occurred:
Employment History
If hired, when can you start?
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If your start date is immediately, select today's date.
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Are you currently employed?
*
Yes
No
May we contact your current employer?
Yes
No
Employment History
*
Please list your current job and previous three jobs.
Start Date
End Date
Employer Name and Address
Position
Supervisor
Pay Rate
Phone Number
Reason for Leaving
Please provide three references who can evaluate you in your professional capacity.
References
Please provide up to three references who can evaluate you in your professional capacity.
Name
Employer
Position
Telephone
If you would like to upload your resume or CV, you may do so here.
Drop files here or
Select files
Accepted file types: pdf, doc, docx, Max. file size: 5 MB, Max. files: 5.
You may upload up to five files simultaneously. Only files with extensions .doc, .docx and .pdf can be uploaded.
Education
High School Education
*
High School Name
High School Address
High School Course/Major
High School Year of Graduation
Did you graduate high school?
*
Yes
No
Currently Enrolled
College Education
College Name
College Address
College Major/Subject
College Year of Graduation
Did you graduate college?
Yes
No
Currently Enrolled
Graduate School Education
Graduate School Name
Graduate School Address
Graduate School Major/Subject
Graduate School Year of Graduation
Did you graduate from your graduate school program?
Yes
No
Currently Enrolled
Technical or Professional Education
Technical or Professional School Name
Technical or Professional School Address
Technical or Professional School Major/Subject
Technical or Professional School Year of Graduation
Did you graduate from your technical or professional school program?
Yes
No
Currently Enrolled
Other Education
Do you have any other education you would like to mention?
No
Yes
Other Education
School Name
School Address
School Major/Subject
Year of Graduation
Did you graduate from this program?
Yes
No
Currently Enrolled
Professional Licenses or Certifications
Licenses or Certifications
You may add up to ten licenses or certifications
Type
State Issued
Registration #
Effective Date
Expiration Date
Do you have any other special knowledge, skills or qualifications or other languages?
Please list any computer hardware or software skills?
*
Application Authorization
Medical Associates of Erie is an equal opportunity employer. No person shall on the basis of race, color, religion, gender, national origin, ancestry, ethnicity citizenship, age, genetic characteristics, disability, or any other characteristic protected by applicable law be unlawfully excluded from consideration for employment.
Employment opportunities shall be provided for applicants with disabilities and reasonable accommodation(s) shall be made to meet the physical or mental limitations of qualified applicants or employees.
I authorize Medical Associates of Erie, or its agent to perform such investigations and inquires of my personal, employment, or medical history and other related matters as may be necessary in arriving at an employment decision. I release employers, schools or persons from all liability in responding to inquires in connection to this application for employment. Medical Associates of Erie requires applicants who receive an offer of employment to have positive employment references, pass a physical exam, background check and drug screen.
I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of Medical Associates of Erie.
I certify that answers given herein are true and complete. I further understand that false or misleading information provided in the employment application or interview may result in canceling further consideration of this application or discharge.
*
Yes
No
Name
This field is for validation purposes and should be left unchanged.
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