Apply For A Position Below.

Starting with present or most recent, list all previous employers. Include self-employment, summer, part-time jobs and any period of unemployment. If you need more space, please continue on a separate sheet. Please indicate any change of name or assumed name used. Any gaps in information will cause this to be rejected as an incomplete application.

Name of Three Persons, Not Relatives, Who May Be Contacted at The Present Time.

Please read each statement carefully before signing. I authorize investigation of all statements contained in this application (if I am considered for employment) and hereby authorize previous employers, personal references named, or any other person or persons to whom the company may refer, to give any and all information regarding my background if requested. In the event of my employment to a position at Mid-South Maternal Fetal Medicine, P.C., I will comply with all rules and regulations as set forth within the policies and procedures of the Company, or other communications the Company may distribute to its employees. If a job offer is made, I agree to complete a health evaluation which any include a physical examination by a physician selected by Mid-South Maternal Fetal Medicine, P.C. (at the Company’s expense). Additionally, I authorize Mid-South Maternal Fetal Medicine, P.C., to supply my employment record in whole or in part to only those agencies having legal or proper interest. I further authorize Mid-South Maternal Fetal Medicine, P.C. to use my photograph in connection with its advertising and public relations programs, in the event that I should become an employee. I hereby certify that I have read and do understand all of the above statements, that all statements made by me are true and accurate to the best of my knowledge, and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that any false statements or material omissions may be grounds for refusal to hire, or for immediate dismissal. I certify that I am at least 18 years of age and am legally authorized to work in the United States. Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Mid-South Maternal Fetal Medicine, P.C. and myself for either employment or the providing of any benefit. I further understand that if I am employed by Mid-South Maternal Fetal Medicine, P.C., my unemployment will be for no definite term (at-will), and that either I or my employer will have the right to terminate the employment relationship at any time, with our without cause. I also understand that this status can only be altered by a written contract of employment which is specific to all material terms and is signed by both an officer of the employer and myself. I understand that as a condition of this application and any employment with Mid-South Maternal Fetal Medicine, P.C., I may be required to submit to testing for the presence of drugs and alcohol. I hereby consent to such testing. I further acknowledge that no promises regarding employment have been made to me, and that no promise or guarantee is binding upon the employer unless made in a written contract as described above.