Mount Vernon Animal Hospital 8623 Richmond Highway Alexandria, Va 22309 (703) 360-6600 www.mtvernonanimalhospital.com mtvernonanimalhospital@gmail.com Application for Employment Name________________________________________ Address______________________________________ _____________________________________________ Phone number_________________________________ Are you a US citizen or do you have a green card?_____ Position desired________________________________ Date you can start_______________________________ Salary requirement______________________________ Are you currently employed? Yes / No If so, can we contact your current employer? Yes / No Education School Did you graduate? High School_________________________________________ College_____________________________________________ Trade School_________________________________________ Other (indicate)_______________________________________ General information Please list any special skills or training that you bring to this position ______________________________________________________ ______________________________________________________ ______________________________________________________ Work Experience (begin with most recent employer) Date employed Name/address of employer Position Reason you left 1.__________________________________________________________________ ____________________________________________________________________ 2.__________________________________________________________________ ___________________________________________________________________ 3.__________________________________________________________________ ____________________________________________________________________ 4.__________________________________________________________________ ____________________________________________________________________ Professional references Name Phone number___ Years known______________ 1.__________________________________________________________________ 2___________________________________________________________________ 3.___________________________________________________________________ Personal references Name Phone number___ Years known______________ 1.__________________________________________________________________ 2___________________________________________________________________ 3.___________________________________________________________________ “I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of any statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the Mount Vernon Animal Hospital from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the Mount Vernon Animal Hospital has any authority to enter into any agreement for employment for any specified length of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.” Date_____________________________ Signature________________________________ Do not write below this line - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Interview scheduled_______________________ Remarks__________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Hire date____________________ Position_____________________ Start date____________________ Salary_______________________