Application for Employment "*" indicates required fields Blanco Veterinary Clinic, Inc. is an equal opportunity employer. As such, employment decisions for applications and employees are made without regard to race, color, religion, sex, age, national origin, or disability (if able to perform the essential functions of the job with or without the aid of a reasonable accommodation).Personal InformationDate* MM slash DD slash YYYY Name* First Last Present Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Driver's License Number* Date of Birth* MM slash DD slash YYYY Email Additional Contact PhoneEmployment DesiredPosition Date you can start MM slash DD slash YYYY Salary Desired Are you presently employed? Yes No If so, may we contact your present employer? Yes No Present Employer's Name Present Employer's PhoneGeneral QuestionsAre you legally authorized to work in the United States of America?* Yes No If yes, can you provide documents to establish your eligibility?* Yes No (I.E. passport, driver’s license, social security)Can you fulfill the job duties and responsibilities of the position for which you are applying as they have been described to you with or without a “reasonable” accommodation?* Yes No Are you available for the work hours required?* Yes No Can your vacations be arranged at practice convenience?* Yes No Do you illegally use drugs?* Yes No Do you smoke?* Yes No Have you been vaccinated for Rabies?* Yes No If, no, are you willing to be vaccinated for Rabies before starting the position?* Yes No Check the days of the week that you will NOT be available to work: Mon Tues Wed Thurs Fri Sat Sun Are you interested in Full Time Part Time Volunteer Work Do you have a problem working weekends? Yes No Have you ever been convicted of a felony? Yes No A conviction will not necessarily be bar to employment. Please describe the nature of the conviction, the date of conviction, and your rehabilitation since: Office Skills Keyboard Skills* Yes No What is your Skill Level?* Fair Good Excellent Bookkeeping* Yes No What is your Skill Level?* Fair Good Excellent Computer* Yes No What is your Skill Level?* Fair Good Excellent Word Processing* Yes No What is your Skill Level?* Fair Good Excellent Excel* Yes No What is your Skill Level?* Fair Good Excellent Multi-Line Phone Skills* Yes No What is your Skill Level?* Fair Good Excellent Account Collections* Yes No What is your Skill Level?* Fair Good Excellent Treatment Presentations* Yes No What is your Skill Level?* Fair Good Excellent Fee Presentations* Yes No What is your Skill Level?* Fair Good Excellent Medical Terminology* Yes No What is your Skill Level?* Fair Good Excellent Appointment Scheduling* Yes No What is your Skill Level?* Fair Good Excellent Avimark Program* Yes No What is your Skill Level?* Fair Good Excellent 10 Key Competency* Yes No What is your Skill Level?* Fair Good Excellent Clinical Skills CPR Training* Yes No What is your Skill Level?* Fair Good Excellent Urinalysis* Yes No What is your Skill Level?* Fair Good Excellent Blood Collection* Yes No What is your Skill Level?* Fair Good Excellent Take/Develop/Mount X-rays* Yes No What is your Skill Level?* Fair Good Excellent Injections, IV, etc* Yes No What is your Skill Level?* Fair Good Excellent Anesthesia* Yes No What is your Skill Level?* Fair Good Excellent Fecal Tests* Yes No What is your Skill Level?* Fair Good Excellent Animal Restraint* Yes No What is your Skill Level?* Fair Good Excellent Blood Lab* Yes No What is your Skill Level?* Fair Good Excellent OSHA & Safety Regulations* Yes No What is your Skill Level?* Fair Good Excellent Animal Husbandry* Yes No What is your Skill Level?* Fair Good Excellent Do you have any Veterinary Experiences? Yes No Please describeDo you have any Animal Experiences? Yes No Please describeDo you have any Office Experiences? Yes No Please describeEducationHigh SchoolName of School / City, StateNumber of Years AttendedDid you Graduate? (Y/N)Month/Year of GraduationCourse / Major StudiedCollegeName of School / City, StateNumber of Years AttendedDid you Graduate? (Y/N)Month/Year of GraduationCourse / Major StudiedSpecial Courses or TrainingName of School / City, StateNumber of Years AttendedDid you Graduate? (Y/N)Month/Year of GraduationCourse / Major StudiedAdditional Special Courses or TrainingName of School / City, StateNumber of Years AttendedDid you Graduate? (Y/N)Month/Year of GraduationCourse / Major StudiedSubjects of special study or research work US Military or Naval Service Rank Are you a present member in the National Guard or Reserves? Yes No Former EmployersList below your former employers, starting with last one first, including self-employment or unemployment. Answer all questions here and throughout this employment application – Do NOT substitute with a resume.Name of Employer First Last PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employment Dates: from and to (month and year) Position(s) Held: Supervisor’s Name and Title: Average number of hours worked per week: Rate of Pay (starting and ending): Your full name at time of employment: Describe your duties:Give your reasoning(s) for leaving:May we contact this employer? Yes No Name of Employer First Last PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employment Dates: from and to (month and year) Position(s) Held: Supervisor’s Name and Title: Average number of hours worked per week: Rate of Pay (starting and ending): Your full name at time of employment: Describe your duties:Give your reasoning(s) for leaving:May we contact this employer? Yes No Name of Employer First Last PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employment Dates: from and to (month and year) Position(s) Held: Supervisor’s Name and Title: Average number of hours worked per week: Rate of Pay (starting and ending): Your full name at time of employment: Describe your duties:Give your reasoning(s) for leaving:May we contact this employer? Yes No ReferencesGive the names of three persons not related to you, whom you have known for at least 12 monthsName / RelationshipAddress and Phone NumberBusinessNumber of Years Acquainted Add RemoveWhat are the qualities that would make you the best candidate for the job? What are your goals in 12 months from now? We take responsibility seriously, are you prepared for a high responsibility job? Yes No WE ARE AN EQUAL OPPORTUNITY EMPLOYERPLEASE READ THE FOLLOWING AND SIGN BELOW GENERAL AGREEMENT I hereby credit that the foregoing statements are true, correct, and complete and I understand that any false statements or omission may be considered sufficient cause for rejection of this application or for dismissal from employment if such false statement or omission discovered subsequent for employment. I understand and agree that, if employed, my employment may be terminated at any time without prior notice, regardless of the date of payment of my wage salary. If this application is considered favorably, I agree to abide by and comply with all rules and regulations of the Business as they currently exist and/or as they are modified from time to time during my employment. Signature*Date* MM slash DD slash YYYY Application forms will be retained for a period of 12 months If hired at Blanco Veterinary Clinic, Inc. it will be a 90 day trial basis NameThis field is for validation purposes and should be left unchanged.
