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Medical Associates of Erie Employment Application

Step 1 of 5

Personal Data
Legal Name*
First Last
Email*
Phone*
Please enter your primary phone number.
Address*
Street Address Address Line 2 City State ZIP Code
Have you ever interviewed with MAE or any of its affliates (LECOM, Millcreek Community Hospital, LECOM Wellness Center, LECOM Senior Living Center)?*
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)?*
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)?*
If yes, please list their name, who they are employed by and job title.
Are you a U.S. citizen?*
Are you at least 18 years old?*
Are you at least 16 years old?*
If you are under 18, do you have a valid work permit?*
Are you currently employed?*
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.
How did you learn about this job opening?*
- Advertisement
- Employment Agency
- Friend
- Walk-in
- Relative
- Other

Background
May we contact your current employer for references*
Will you be able to perform the essential job functions for the position you are applying for with our without reasonable accommodations?*
Have you ever been convicted of a crime, excluding misdemeanors and summary offenses, which have not been annulled, expunged or sealed by court?*
*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?*
If your start date is immediately, select today's date.
Are you currently employed?*
May we contact your current employer?
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

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?*
College Education
College Name College Address College Major/Subject College Year of Graduation
Did you graduate college?
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?
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?
Other Education
Do you have any other education you would like to mention?
Other Education
School Name School Address School Major/Subject Year of Graduation
Did you graduate from this program?
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.*
Name
This field is for validation purposes and should be left unchanged.

Start Date	End Date	Employer Name and Address	Position	Supervisor	Pay Rate	Phone Number	Reason for Leaving

Type	State Issued	Registration #	Effective Date	Expiration Date

Test - LECOM Health

Test

Medical Associates of Erie Employment Application

Step 1 of 5

Personal Data

Background

Employment History

Please provide three references who can evaluate you in your professional capacity.

Education

Other Education

Professional Licenses or Certifications

Application Authorization