Advanced Acupuncture Professional Training / Santa Monica - Arcadia Wellness Centers and Acupuncture

PROFESSIONAL TRAINING APPLICATION

(PRE-EMPLOYMENT QUESTIONNAIRE)

PERSONAL INFORMATION

First Name	Middle Initial
Last Name
Social Security Number
Present Address
City
State	Zip Code
Phone Number
Permanent Address
City
State	Zip Code
Phone Number
Are You 18 Years Or Older?	Yes No
E-Mail
Are You Prevented From Lawfully Becoming Employed In This Country Because Of Visa Or Immigration Status? Yes No

EMPLOYMENT DESIRED

Position
Date You Can Start
Salary Desired
Are you available to work full time: Full Time? Part Time?
Are you employed now? Yes No
If so, may we inquire of your present employer?
Ever applied to our company before? Yes No
	When? Where?
Ever worked for our company before? Yes No
	When? Where?
Was termination:	Voluntary? or Involuntary?
Exact reason for leaving
Name of last supervisor at our company?
Who referred you to our company?

FORMER EMPLOYERS

Name of present or last employer
Address
Starting Date	Ending Date
Hr/Mo Starting Salary	Hr/Mo Final Salary
Job Title
May we contact your immediate supervisor? Yes No
Name of immediate supervisor
Title of immediate supervisor
Description of work
Was termination?: Voluntary Involuntary
Exact reason for leaving

2. Name of former employer
Address
Starting Date	Ending Date
Hr/Mo Starting Salary	Hr/Mo Final Salary
Job Title
May we contact your immediate supervisor? Yes No
Name of immediate supervisor
Title of immediate supervisor
Description of work
Was termination?: Voluntary Involuntary
Exact reason for leaving

3. Name of former employer
Address
Starting Date	Ending Date
Hr/Mo Starting Salary	Hr/Mo Final Salary
Job Title
May we contact your immediate supervisor? Yes No
Name of immediate supervisor
Title of immediate supervisor
Description of work
Was termination?: Voluntary Involuntary
Exact reason for leaving

4. Name of former employer
Address
Starting Date	Ending Date
Hr/Mo Starting Salary	Hr/Mo Final Salary
Job Title
May we contact your immediate supervisor? Yes No
Name of immediate supervisor
Title of immediate supervisor
Description of work
Was termination?: Voluntary Involuntary
Exact reason for leaving

EDUCATION

	Name and Location	Years Attended	Did You Graduate?	MJR, MNR Studied
Grammar School
High School
College
Trade, Business Or Correspondence School

REFERENCES
GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR

NAME	ADDRESS	BUSINESS	YEARS ACQUAINTED

MISCELLANEOUS

Subject of special or research work
Special training
Special skills
Do you have any commitments to another entity, business or person that might affect your employment with our company? Yes No
Explain fully

I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND I UNDERSTAND THAT IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF I AM EMPLOYED, MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME. IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE COMPANY'S RULES AND REGULATIONS, AND I AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT EITHER MY OR THE COMPANY'S OPTION. I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MY EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME BY THE COMPANY. I UNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAN IT'S PRESIDENT, AND THEN ONLY WHEN IN WRITING AND SIGNED BY THE PRESIDENT, HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.

I HAVE READ THE FOLLOWING STATEMENT YES NO