(919) 469-0771
1040 Darrington Dr. Ste 102, Cary, NC 27513

The Peak Health Center
Employment Application

The Peak Health Center is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of any characteristics protected by law, including race, color religion, age, sex, national origin, or disability.

PERSONAL:

Home Work Cell
Yes No
Yes No

(If offered employment, you will be required to provide documentation to verify eligibility)


EDUCATION:

Please indicate education or training that you believe qualifies you for the position you are seeking.

High-school

1 2 3 4
Yes No
Yes No

College and/or Vocational School

1 2 3 4

Other Training or Degree

Professional


EMPLOYMENT:

List last employer first, including US Military Service.

Yes No

Job 1

Home Work Cell

Dates of Employment:

Job 2

Home Work Cell

Dates of Employment:

Job 3

Home Work Cell

Dates of Employment:


RECORD OF CONVICTION:

Yes No

(A conviction will not necessarily automatically disqualify you for employment. Rather, such factors as your age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.)


REFERENCES:

Reference #1:

Reference #2:

Reference #3:


APPLICANT’S CERTIFICATION AND AGREEMENT

"I hearby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and I authorize Peak Health Center to verify their accuracy and to obtain reference information on my work performance. I hereby release Peak Health Center from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information.

I understand that, if I am employed by Peak Health Center, falsified statements of any kind or omissions of facts called for on this application, shall be considered sufficient basis for dismissal. I authorize Peak Health Center to make a thorough investigation of all statements contained on this application about my past employment, education, and other activities. I release liability from all persons and organizations supplying such information.

I understand that should an employment offer by extended to me and accepted, I will fully adhere to the policies, rules and regulations of employment of the employer. I also understand that Peak Health Center is an “at will” employer. I understand that either I or Peak Health Center may terminate any employment agreement for any reason or for no reason, at any time with or without notice.

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.""

By the applicant entering their name in the box below, they are electronically signing this application and it carries the same legal value as if it were signed by the applicant in person.


Yes | No

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