Employment Application

Use the form below to submit your application via email.

*Required Fields
*POSITION APPLIED FOR:   
PERSONAL
*First Name:
*Last Name:
Middle Initial
*Social Security Number:
Present Address:
City:
State, ZIP:
*E-Mail:
Have you been employed under other names? Yes   No
List Name(s):
*Home Telephone No.:
Work Telephone No.:
May we contact you at work?
How did you find out about this job opening?
*Are you related to anyone now employed by Cooper Clinic? Yes   No
If Yes, Name:          
  Department: 
  Relationship:
*Have you ever been employed by this facility?  Yes   No
“if yes”, include dates of employment and position held.
Are you a U.S. Citizen or an alien legally authorized to work in the U.S? Yes   No
May we contact your present employer? Yes   No


*Have you ever been convicted of, or plead guilty to, a crime other than misdemeanor traffic violations?
                                     
Yes  No

Answering “yes” to the above question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

If yes, please provide date(s) and details:
 

 

Cooper Clinic, P.A.,   6801 Rogers Ave.,  Fort Smith, AR 72903  •  479-274-2000 or 800-333-1305    ©2009
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