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Employment Application
Employment Application
Name
First
Last
Date
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
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Algeria
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Anguilla
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Austria
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Belize
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Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
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Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Country
Phone
(Required)
Email
(Required)
Any Schedule Restrictions?
(Required)
Position of Interest
(Required)
Salary Requested
(Required)
Were you ever employed here? If yes, when?
(Required)
Educational Background
High School
City/State
Years Completed
Degree/Major
College/University
City/State
Years Completed
Degree/Major
Gratuate School
City/State
Years Completed
Degree/Major
Trade School
City/State
Years Completed
Degree/Major
Qualifications: List any applicable skills or certifications that you have received that may be of value to your employment:
Are you a US citizen and able to prove it?
(Required)
Yes
No
If not, do you have the legal right to work in the US?
(Required)
Yes
No
Are you 18 years or older?
(Required)
Yes
No
If not, please specify age:
Do you speak or read any other launguages fluently besides english?
(Required)
Yes
No
If yes, which one(s):
Have you been convicted of a felony crime?
(Required)
Yes
No
Are there any criminal charges pending against you?
(Required)
Yes
No
General Information
Do you have reliable transportation to and from work?
(Required)
Yes
No
What do you plan to be doing in five years?
(Required)
Are there any restrictions you have to your schedule that would interfere with your employment with us?
(Required)
Yes
No
If yes, please explain.
Are you aware that working in a veterinary practice may require you to work extra hours or overtime?
(Required)
Yes
No
Are you able to perform all of the duties listed in the job description?
(Required)
Yes
No
Tell us about your greatest customer service achievement or your best example of helping a client or customer at work.
(Required)
Tell us why you would like to work here, how you can help Belmont Animal Hospital, and how Belmont Animal Hospital can help you.
(Required)
Employment History
Please fill out the below forms from most recent to least
Employment Dates
Employer's Name and Address
Position & Job Duties
Reason for Leaving
Wage/Salary
Employment Dates
Employer's Name and Address
Position & Job Duties
Reason for Leaving
Wage/Salary
Employment Dates
Employer's Name and Address
Position & Job Duties
Reason for Leaving
Wage/Salary
Is the information relative to change in name, use of an assumed name, maiden name, or nickname necessary to check you employment history? If yes, please explain:
Do you authorize us to contact your previous and/or present employer for reference prior to employment with this business?
(Required)
Yes
No
Current Employer
(Required)
Yes
No
Former Employers
(Required)
Yes
No
Is there is anything else you would like us to know about you?
Signature
I certify that the information contained in this application is correct to the best of my knowledge. I
authorize investigation of all matters contained in this application and agree that any misleading or
false statements would be cause for rejection of this application or would be sufficient cause for
dismissal after employment begins. I understand that my continued employment will be based on
my satisfactory performance and the satisfactory completion of the Probationary Period of my
employment. I hereby authorize my past and present employers to furnish Lovers Lane Animal
Medical Center with their records of my employment.
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