3105 Lomita Boulevard,
Torrance, CA 90505
(310) 784-4923
Job Line (310) 784-4995
An Equal Opportunity Employer

Online Application for Employment
Part 1/4


Our Quality Service Speaks For Itself.

Personal

Name (Last)  (First)  (Middle) 
Address
City State Zip
Home Phone   Message Phone
Social Security No.
Age if Under 18:    E-mail Address

Positions Applied For

Indicate position(s) applied for; add specialty where applicable.
Position 1
Position 2
Position 3

Date Available:     Minimum Salary Acceptable: $   Hourly

Are you willing to work?
Days Evenings Nights Weekends Full Time Part Time Per Diem

How were you referred to POSS? Employee Walk-in Advertisement
Name of Newspaper, Employee, etc. 

General Information

Have you ever applied to or worked for POSS before? Yes No
If yes, explain 


If hired, can you provide proof that you are a U.S. citizen or legally authorized to be employed in the United States? Yes No

Have you ever been convicted of a felony?  Yes No 
If yes, explain. (Record of conviction does not disqualify you from employment consideration.)


Referral Source:  Advertisement Job Line Job Fair

Other


Employee Referral (Name of employee )

Have you ever been discharged from a job?  Yes No
If yes, give employer, date and reason for terminatiion:


May we contact your current employer for a reference?  Yes No

Can you physically perform the essential functions of the applied position, with or without accommodations. What accommodations would you require?
Skills

Check the skills you posess:

Typing Speed: wpm    Dictaphone Medical Terminology PBX

Short Hand:    wpm    Ten-Key     Data Entry

Word Processing: Type                       Computer: Type

                                  wpm

Other skills not listed above:


Professional License/Certification     Expiration Date

License Number State where issued

Are there any restrictions on your license? (RN, LVN, Pharmacy, etc.) Yes No

If yes, please explain. 

Education

High School
Name
Location
Name Enrolled Under 
Last Year Completed 9 10 11 12
Diploma Yes No


College
Name
Location
Dates Attended
Name Enrolled Under 
Major Field 
Diploma/Degree


School of Nursing
Name
Location
Dates Attended
Name Enrolled Under 
Major Field 
Diploma/Degree


Professional/Technical School
Name
Location
Dates Attended
Name Enrolled Under 
Major Field 
Diploma/Degree

Employment History

This section must be completed even if supplemented by a resume. List all employment for the past five years, beginning with most recent employment. Include all employment, military service and volunteer service. Explain all lapses in employment in the Supplemental Information section of this form.

1. (present or most recent)
Employer Name
Employer Address
City State Zip
Scheduled hours per week
Name of Supervisor
Title of Supervisor
Telephone Number/Extension
Dates of Employment:  From To
Salary $ Hourly/Monthly/Annual
Name under which employed:
Job Title
Reason for Leaving
Job Duties and Responsibilities
Eligible for Rehire? Yes No

2. (next previous)
Employer Name    
Employer Address  
City State Zip
Scheduled hours per week  
Name of Supervisor 
Title of Supervisor 
Telephone Number/Extension  
Dates of Employment:  From   To
Salary  $   Hourly/Monthly/Annual
Name under which employed:  
Job Title 
Reason for Leaving 
Job Duties and Responsibilities 
Eligible for Rehire?   Yes No

3. (next previous)
Employer Name    
Employer Address  
City State Zip
Scheduled hours per week  
Name of Supervisor 
Title of Supervisor 
Telephone Number/Extension  
Dates of Employment:  From   To
Salary  $   Hourly/Monthly/Annual
Name under which employed:  
Job Title 
Reason for Leaving 
Job Duties and Responsibilities 
Eligible for Rehire?   Yes No

4. (next previous)
Employer Name    
Employer Address  
City State Zip
Scheduled hours per week  
Name of Supervisor 
Title of Supervisor 
Telephone Number/Extension  
Dates of Employment:  From   To
Salary  $   Hourly/Monthly/Annual
Name under which employed:  
Job Title 
Reason for Leaving 
Job Duties and Responsibilities 
Eligible for Rehire?   Yes No

5. (next previous)
Employer Name    
Employer Address  
City State Zip
Scheduled hours per week  
Name of Supervisor 
Title of Supervisor 
Telephone Number/Extension  
Dates of Employment:  From   To
Salary  $   Hourly/Monthly/Annual
Name under which employed:  
Job Title 
Reason for Leaving 
Job Duties and Responsibilities 
Eligible for Rehire?   Yes No
Supplemental Information

Please explain any breaks in your employment history.

Include any additional information you wish to provide
(your special abilities, skills, achievements, professional honors or
awards, special activities in which you have been involved, etc.)


Physician Office Support Services has adopted a policy pertaining to equal employment opportunity which includes, but is not limited to, the following: POSS will make all decisions regarding recruiting, hiring, compensation benefits, training, placements, transfers and the promotion of employees solely upon the basis of the individual's qualifications for the position being filled and in full compliance with all applicable laws and regulations prohibiting discrimination in employment on the basis race, color, religion, ancestry, national origin, age (over 40 years), sex, marital status, disability, or U.S. veteran status. Physician Office Support Services will not refuse to hire a disabled applicant who is capable of performing the essential functions of the job with or without reasonable accommodation.



PLEASE READ THE FOLLOWING CAREFULLY BEFORE SUBMITTING THE APPLICATION FORM

I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the statements checked by POSS unless I have indicated to the contrary. I authorize the references listed above to provide POSS any and all information concerning my previous employment and any pertinent information that they might have. Further, I release all parties and persons from any and all liabilities and damages that may result from furnishing information to POSS as well as from the use or disclosure of such information by POSS. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, in my dismissal from employment.

I agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice, at any time, either at my option or at the option of POSS. I understand that no employee or representative of POSS has any authority to enter into any other agreement for employment contrary to this "at will" policy, except the President of POSS who may do so only in writing and setting forth a specified term. I also understand that all offers of employment are conditioned on: 1) the provision of satisfactory proof of my identity; 2) legal authority to work in the U.S.; 3) successful completion of a pre-employment health assessment; 4) background check; 5) reference check.

This application will be considered active for a maximum of ninety (90) days. If you wish to be considered for employment after that time, you must resubmit another application.

Type Name Agreed Date


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