NOW PATIENTS MAY CONTACT US ON THE WEB!

Exciting new functionality on the site includes the ability for our patients to request, cancel, or reschedule an appointment through an online request form, request prescription refills, check on test results, or to ask our staff quick questions by email.

Personal Information

*Required Fields

*Date

*Last name:

*First name:

Present Address1

	Street	City	State	Zip

Present Address2

	Street	City	State	Zip

Phone No*

Are you 18 years or Older?

Y N

Can you, after employment, submit verification

of your legal right to work in the United States?

Y N

EMPLOYMENT DESIRED

Position

Date you can start

Salary desired

Are you employed Now?

Y N

May we inquire of your present employer?

Y N

Ever applied to this company before?

Y N

Where?

When?

Referred by

Have you ever been convicted of a felony?

Y N

(Note : a conviction will not necessarily disqualify applicant from the desired position.)

EDUCATION	Location	Years attended	Did you graduate?	Subjects studied



Grammar School



High School



College



Trade, Business or Correspondence School

Are you able to perform the essential functions of the job for which you are applying, either with or without

reasonable accommodation?

Y N.

If no, describe the functions that cannot be performed:

(Note: Virginia Beach Obstetrics and Gynecology will consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Employment may be subject to passing a medical examination.)

GENERAL

Subjects of special study or research work

Special skills

Activities (civic, athletic, etc.)

(exclude organizations whose name indicates the race, creed, sex, age, marital status, color or national origin of its members)

US Military or

Present membership in

Present membership in Naval Service

Y N

National Guard or Reserves

Y N

FORMER EMPLOYERS Give the names of three persons not related to you, whom you have known at least one year.

Date -

MO/YR

Name and address

Salary

Position

Reason for leaving

From

Which of these jobs did you like best?

What did you like most about that job?

REFERENCES Give the names of three persons not related to you, whom you have known at least one year.

Name	Address and phone	Business	Years acquainted














In case of emergency notify

Name	Address	Phone

I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, ANY FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU. I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS “AT-WILL” AND AS SUCH IS FOR NO DEFINITE PERIOD AND MAY BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE AND WITHOUT CAUSE. THIS “AT-WILL” EMPLOYMENT RELATIONSHIP CAN ONLY BE CHANGED IN WRITING SIGNED BY THE EXECUTIVE DIRECTOR OF VIRGINIA BEACH OBSTETRICS & GYNECOLOGY. SUBMISSION OF THIS APPLICATION DOES NOT CONSTITUTE AN OFFER OF EMPLOYMENT, ONLY A REQUEST TO INQUIRE ABOUT CAREER OPPORTUNITIES.

I AGREE *

DATE *

Enter the Security Code shown

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