Employment Application

Patient First Name

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Patient Last Name

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Address

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Primary Phone number

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How did you learn about the CIMG Medical Assistant Apprenticeship Program

CIMG Website

College of Southern Maryland

Other

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If you selected Other to the previous question, how did you learn about the CIMG Medical Assistant Apprenticeship Program?

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Education, High School: Please list the name and location of the High School you attended.

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Education, High School: Did you graduate?

Yes

I have received my GED

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Education, Trade/Business School: Please list the name and location of the trade or business school you attended.

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Education, Trade/Business School: Did you graduate?

Yes

Not applicable

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Education, College/University: Please list the name and location of the college or university you are attending or did attend.

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Education, College/University: Did you graduate?

Yes

In progess

Not applicable

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Please list any professional designations or licenses currently held.

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Please describe additional skills, training, or ability you would like to have us consider in evaluating your qualifications. Include software:

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Most Recent Employer: Please list the company name, address, phone number, and dates of employment for your current/most recent employer?

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Most Recent Employer: Please list your job title, describe the duties of the position held, and your reason for leaving if applicable.

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Most Recent Employer: Please list your supervisors name. May we contact for a reference?

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Former Employer 1: Please list the company name, address, phone number, and dates of employment for your current/most recent employer?

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Former Employer 1: Please list your job title, describe the duties of the position held, and your reason for leaving if applicable.

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Former Employer 1: Please list your supervisors name. May we contact for a reference?

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Former Employer 2: Please list the company name, address, phone number, and dates of employment for your current/most recent employer?

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Former Employer 2: Please list your job title, describe the duties of the position held, and your reason for leaving if applicable.

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Former Employer 2: Please list your supervisors name. May we contact for a reference?

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Reference 1: Please list a professional reference (preferably a current/previous supervisor). Include name, relationship, phone number, and years known.

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Reference 2: Please list a professional reference (preferably a current/previous supervisor). Include name, relationship, phone number, and years known.

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Reference 3: Please list a professional reference (preferably a current/previous supervisor). Include name, relationship, phone number, and years known.

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Have you previously applied or worked at Calvert Internal Medicine Group? If so, in what position and list dates of employment, other names used at time of employment.

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Are you lawfully eligible for employment in the United States?

Yes

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Please Read, Sign, and Date:

IN ACCORDANCE WITH MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE ANY APPLICANT FOR EMPLOYMENT OR PROSPECTIVE EMPLOYMENT OR ANY EMPLOYEE TO SUBMIT TO OR TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR EXAMINATION AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. ANY EMPLOYER WHO VIOLATES THIS PROVISION IS GUILTY OR A MISDEMEANOR AND SUBJECT TO A FINE NOT TO EXCEED $100.

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Medical Examination Consent - Please Read, Sign, & Date:

IF I RECEIVE AN OFFER OF EMPLOYMENT FROM CALVERT INTERNAL MEDICINE GROUP, I CONSENT TO SUBMIT TO ANY LEGALLY PERMISSIBLE MEDICAL OR PHYSICAL EXAMINATIONS, INCLUDING BUT NOT LIMITED TO BLOOD, URINE, BREATH OR OTHER EXAMINATIONS OR TESTS FOR ALCOHOL, DRUGS, PERCEPTION-ALTERING OR CONTROLLED SUBSTANCE USE, THAT MAY BE REQUESTED BY CALVERT INTERNAL MEDICINE GROUP. I UNDERSTAND THAT ANY OFFER OF EMPLOYMENT WILL BE CONTINGENT UPON THE RESULTS OF PRE-EMPLOYMENT MEDICAL OR PHYSICAL EXAMINATIONS, IN THE SOLE DISCRETION OF CALVERT INTERNAL MEDICINE GROUP. I FURTHER AGREE TO TAKE ANY SUCH LEGALLY PERMISSIBLE EXAMINATIONS THAT MAY BE REQUESTED BY CALVERT INTERNAL MEDICINE GROUP DURING MY EMPLOYMENT, SHOULD I BE OFFERED AND ACCEPT A JOB, WITH THE UNDERSTANDING THAT THESE EXAMINATIONS WILL BE PERFORMED BY A HEALTH CARE PROFESSIONAL DESIGNATED BY CALVERT INTERNAL MEDICINE GROUP. I FURTHER HEREBY AUTHORIZE THE RELEASE TO CALVERT INTERNAL MEDICINE GROUP OF ALL RESULTS OF ANY SUCH TESTS OR MEDICAL OR PHYSICAL EXAMINATIONS PERFORMED ON ME AT THAT TIME BY ANY PHYSICIAN OR CLINIC TO WHICH I AM REFERRED BY CALVERT INTERNAL MEDICINE GROUP. I FURTHER AUTHORIZE THE USE OF THIS INFORMATION BY CALVERT INTERNAL MEDICINE GROUP FOR ANY LEGITIMATE PURPOSE, INCLUDING BUT NOT LIMITED TO MY EMPLOYMENT, SUBSEQUENT PERFORMANCE EVALUATIONS, PROMOTION DECISIONS, DISCIPLINE, OR TERMINATION.

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Background Check Release - Please read, sign, and date:

I HEREBY GIVE CALVERT INTERNAL MEDICINE GROUP (CIMG) THE RIGHT TO CONDUCT A THOROUGH BACKGROUND INVESTIGATION AND OBTAIN A CONSUMER REPORT OR INVESTIGATIVE CONSUMER REPORT, AS PERMITTED BY STATE AND/OR FEDERAL LAW, INCLUDING, BUT NOT LIMITED TO: EDUCATION, REFERENCES, CREDIT HISTORY, CRIMINAL BACKGROUND, AND DRIVING RECORDS; AND I RELEASE FROM ALL LIABILITY ALL PERSONS, COMPANIES AND CORPORATIONS SUPPLYING SUCH INFORMATION. I RELEASE, INDEMNIFY, AND HOLD HARMLESS CALVERT INTERNAL MEDICINE GROUP AND ITS SUBSIDIARIES FROM AND AGAINST ANY AND ALL LIABILITY THAT MAY RESULT FROM MAKING SUCH AN INVESTIGATION. I UNDERSTAND THAT ANY OFFER OF EMPLOYMENT MAY BE CONTINGENT UPON THE RESULTS OF THE BACKGROUND CHECK, IN THE SOLE DISCRETION OF CALVERT INTERNAL MEDICINE GROUP

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Representations by Applicant: Please read, sign, & date:

REPRESENTATIONS BY APPLICANT: I HEREBY CERTIFY THAT THE INFORMATION I HAVE PROVIDED IN CONNECTION WITH MY APPLICATION FOR EMPLOYMENT IS TRUE AND COMPLETE. I UNDERSTAND THAT ANY FALSE OR MISLEADING INFORMATION OR MISREPRESENTATIONS BY OMISSION IN MY APPLICATION FORM OR ANY RELATED DOCUMENT, INTERVIEWS OR OTHER ASPECT OF MY APPLICATION CAN RESULT IN MY DISQUALIFICATION AS A CANDIDATE FOR EMPLOYMENT OR MY IMMEDIATE DISCHARGE IF ALREADY EMPLOYED.

I ALSO UNDERSTAND THAT NOTHING CONTAINED IN THIS EMPLOYMENT APPLICATION OR GRANTING OF AN INTERVIEW IS INTENDED TO CREATE AN EMPLOYMENT CONTRACT BETWEEN CALVERT INTERNAL MEDICINE GROUP AND MYSELF FOR EITHER EMPLOYMENT OR FOR GRANTING OF BENEFITS. NO PROMISES REGARDING EMPLOYMENT HAVE BEEN MADE TO ME, AND I UNDERSTAND THAT NO SUCH PROMISE OR GUARANTEE IS BINDING UPON CALVERT INTERNAL MEDICINE GROUP UNLESS MADE IN WRITING. IF AN EMPLOYMENT RELATIONSHIP IS ESTABLISHED, I UNDERSTAND AND AGREE THAT IT IS AT-WILL, MEANING EITHER I OR CALVERT INTERNAL MEDICINE GROUP MAY TERMINATE MY EMPLOYMENT AT ANY TIME WITH OR WITHOUT CAUSE OR NOTICE.

I UNDERSTAND THAT, IF ACCEPTED FOR EMPLOYMENT, IT IS NECESSARY TO ABIDE BY THE RULES AND POLICIES OF CALVERT INTERNAL MEDICINE GROUP AND ANY OF ITS SUBSIDIARIES.

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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