Submit your employment information - Deuk Spine Institute

Employment Form

Employment Application

We are an equal opportunity employer and do not discriminate agains otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, veteran status or any other trait protected by law.

Application Information
Incomplete information could disqualify you from further consideration

Desired Position

Date

Fullname

First Middle Last

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Primary Telephone Number

Cell/Other Number

Email Address

Are you eligible to work in the United States?

Yes

(if offered employment, you will be required to provide document to verify eligibility)

Are you at least 18 years of age?

Yes

Do you have a High School Diploma or Equivalent?

Yes

Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?

Yes

Have you ever been terminated from employment or asked to resign by an employer?

Yes

If yes, please provide company name and details

Have you ever been arrested or convicted of a crime other than a minor traffic offense (including Military Service)?

Yes

If yes, explain

(Pre employment criminal background checks are conducted. Failure to divulge complete information will disqualify you from employment. However, conviction will not necessarily disqualify an applicant from employment)

Employment Desired/Availability

Date Available

Type of Work Desired

Full-Time

Part-Time

Per Diem

Desired Salary $

Per Hour

Annually

Are you currently employed?

Yes

If yes, may we contact your current employer?

Yes

Millennium Medical Management and Surgery Center of Viera expects all employees to work as scheduled. Can you satisfy, with or without reasonable accommodation of any disability, this requirement?

Yes

Can you work longer hours that normal if it is required?

Yes

Can you work at more than once location if it is required?

Yes

Referral Source

How did you hear about us?

Online Job Board (Site)

Social Media (Site)

Employee Referral (name)

Other

Have you ever worked for or applied to Millennium Medical Management and/or Surgery Center of Viera

Yes

If yes, please give date(s)

Reason for Leaving

Do you have any friends or relatives that are currently or were previously employed with Millennium Medical Management and/or Surgery Center of Viera

Yes

If yes, please provide name and relationship to you

Employment History

List all prior employment beginning with the most recent/current employer. Add another sheet as necessary.

Date from

Date to

Employer Name

First Last

Telephone

Starting Based Salary $

Starting Position

Ending Based Salary $

Ending Position

Description of Duties

Reason for Leaving

Date from

Date to

Employer Name

First Last

Telephone

Starting Based Salary $

Starting Position

Ending Based Salary $

Ending Position

Description of Duties

Reason for Leaving

Date From

Date to

Employer Name

First Last

Telephone

Starting Based Salary $

Starting Position

Ending Based Salary $

Ending Position

Description of Duties

Reason for Leaving

Date From

Date to

Employer Name

First Last

Telephone

Starting Based Salary $

Starting Position

Ending Based Salary $

Ending Position

Description of Duties

Reason for Leaving

Please explain any gaps in work history

Education and Training

High School

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Date From

Date to

Did you graduate?

Yes

Degree Earned

High School Diploma

GED

College and/or Vocational School Address

Street Address City State / Province / Region ZIP / Postal Code Country

License(s)

Please list any professional/medical license obtained

License Type

State

Exp. Date

Discipline on file

Yes

N/A

License Type

State

Exp. Date

Discipline on file

Yes

N/A

License Type

State

Exp. Date

Discipline on file

Yes

N/A

Additional Skills/Accomplishments

Computer Software:

Equipment

Miscellaneous

Awards

Professional Affiliations or memberships

References

Please provide information for three individuals, other than family members, who could tell us something about your suitability for work (example: supervisors or co-workers, teachers, counselors, community or other volunteer service leaders, colleagues, etc.)

Name

First Last

Relationship

Telephone

How long have you known?

Name

First Last

Relationship

Telephone

How long have you known?

Name

First Last

Relationship

Telephone

How long have you known?

Skill test, personality, integrity or other assessments, background checks and a drug test may be required.

Certification and Authorization

Certification and Authorization By submitting this application, I hereby certify that the information on this application is true and complete to the best of my knowledge. I understand and agree that nay misrepresentation or omission on this application may result in either rejection of my application or, if hired, dismissal whenever it is discovered. I authorize Millennium Medical Management, LLC/Surgery Center of Viera, LLC and/or its agents to investigate, directly or indirectly, all statements contained on this application. I also authorize the reference, employers, educational institutions, other listed and any other person/entity with any information about me to release any such information to Millennium Medical Management, LLC/Surgery Center of Viera, LLC and/or its agents. I also release all such parties as well as Millennium Medical Management, LLC/Surgery Center of Viera, LLC and its agents from any and all liability or damage that may result from seeking, furnishing or using such information in connection with my applying for employment, employment with Millennium Medical Management, LLC/Surgery Center of Viera, LLC, or any legal obligation. I understand and agree that, if I am hired, I must comply with the rules and policies of Millennium Medical Management, LLC/Surgery Center of Viera, LLC which exist when I am hired or which may come into existence during the course of my employment. I also understand and agree that, if I am hired, my employment will be for no definite period and may, regardless or the date of payment of my compensation, be terminated by me or Millennium Medical Management, LLC at any time, for any or no reason, with or without notice. No representaion to the contrary is valid unless in writing, setting a definite term of employment, and signed by the President of Millennium Medical Management, LLC/Surgery Center of Viera, LLC.

I have been advised that a job offer for some positions is conditioned on the applicant passing, to Millennium Medical Management, LLC/Surgery Center of Viera, LLC's satisfaction, a pre-employment background and/or drug/alcohol test. I have been advised and agree that no handbook, manual, policy and/or procedure of Millennium Medical Management, LLC/Surgery Center of Viera, LLC is intended or should be construed as contactual in nature.

I certify that I have read, understand and will adhere to the foregoing statements

Signature

Date

I HEREBY AUTHORIZE MILLENNIUM MEDICAL MANAGEMENT, LLC and/or SURGERY CENTER OF VIERA, LLC AND ITS DESIGNATED AGENTS TO CONDUCT ANY AND ALL NECCESSARY PRE-EMPLOYMENT INVESTIGATIONS. THIS MAY INCLUDE CRIMINAL BACKGROUND CHECKS, MOTOR VEHICLE INQUIRIES, EMPLOYMENT HISTORY, CREDIT CHECKS, AND OTHER PRE-EMPLOYMENT RESEARCH. THIS INFORMATION WILL BE HELD IN STRICT CONFIDENCE.

Name

First Last

Signature

Date

Social Security Number

Date of Birth

MILLENNIUM MEDICAL MANAGEMENT. LLC

SURGERY CENTER OF VIERA, LLC

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