Blair Orthopedic Associates and Sports Medicine

Online Pre-Employment Questionnaire

Today's Date:

PERSONAL INFORMATION

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip Code:

Home Telephone

Email Address:

EMPLOYMENT DESIRED

Position:

How did you hear about this position?

Date Available:

Have you ever applied to Blair Orthopedic Associates before?

Yes No

If yes, what position and when:

Do you have any friends or relatives employed by Blair Orthopedic Associates?

Yes No

If yes, please provide their name/relation:

Are you currently employed?

Yes No

Are you currently on lay off status or subject to recall?

Yes No

If hired, can you provide proof of U.S. citizenship or
proof of your legal right to work in the U.S. ?

Yes No

Are you able to perform all essential functions of the job
for which you are applying with reasonable accommodations?

Yes No

If driving is a requirement of the position applied for,
have you in the last seven years been convicted of Driving Under the Influence (DUI)?

Yes No

If hired, do you have a reliable means of transportation to and from work?

Yes No

If hired, would you be able to work overtime as needed?

Yes No

Have you ever been convicted of a felony or misdemeanor?

Yes No

If yes, please explain:

EDUCATION

	Name and Location of School	Total Years of Study	Course of Study	Degree/ Diploma
High School
Undergraduate College
Graduate/ Professional
Other (Specify)

List any seminars, classes or other education not listed above which may help qualify you for this position?

Identify formal job training that relates to this position:

Identify what skills or certification you possess related to this position:

Describe what you believe are the most unique features of your work history:

U.S. Military Service:

Rank:

FORMER EMPLOYERS

Please list below all present and past employers over the past ten years, starting with your most recent employer.

1. Employer

(Former) Supervisor

Phone Number

May we contact this employer?

Yes No

Job Position(s)

Salary

Start Date

End Date

Reason for Leaving:

2. Employer

Former Supervisor

Phone Number

May we contact this employer?

Yes No

Job Position(s)

Salary

3. Employer

Former Supervisor

Phone Number

May we contact this employer?

Yes No

Job Position(s)

Salary

PROFESSIONAL REFERENCES

Please list three persons below that are not related to you, who have knowledge of your work performance within the last five years.

Current and/or former supervisors are preferred.

Name	Company	Phone	Relationship	Yrs Acquainted
1.
2.
3.

AUTHORIZATION

Please read each statement closely and acknowledge your understanding by checking Yes or No.

Equal Employment Opportunity Statement

Blair Orthopedic Associates is committed to the principles of equal employment opportunity and is committed to make employment decisions based on merit. We are committed to complying with all Federal, State and local laws providing for equal employment opportunities, as well as all laws related to terms and conditions of employment. Blair Orthopedic Associates desires to maintain a work environment that is free of sexual harassment and discrimination due to race, religion, color, national origin, physical or mental disability, age or any other status protected by Federal, State or local laws. Blair Orthopedic Associates will make reasonable efforts to accommodate those physical or mental limitations of an otherwise qualified employee unless undue hardship would result for the Company.
Yes No

Complete and Accurate Information

I certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application. I understand that any omission or misstatement of material fact on this application, or any other document used to secure employment, shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
Yes No

Investigation Authorization

I authorize investigation into all statements and references contained in this application. Said investigation may include credit, driving, criminal background, references and other background checks. By applying for this job, I also authorize post-hire investigation into my credit, driving and criminal background.
Yes No

Company Obligation

I understand and agree that Blair Orthopedic Associates acceptance of this job application does not mean that a position for which I am qualified is open (unless specifically posted) or that the company has agreed to hire me. I understand that Blair Orthopedic Associates is under no obligation to hire me as the result of accepting this completed application.
Yes No

BY SUBMITTING THIS ONLINE JOB APPLICATION, I VERIFY I HAVE READ AND UNDERSTAND THE ABOVE POLICY STATEMENTS AND AGREE TO BE BOUND BY THEM IF EMPLOYED BY BLAIR ORTHOPEDIC ASSOCIATES.