Office Employment Application | Vic The Picc – Victory Infusion Consultants, Inc

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Office Employment Application

Phone: 866-971-8422
Fax: 888.723.8422

Step 1 of 6

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Basic Info
Name*
First Middle Last
Present Address*
Street Address City State ZIP Code
Email*
Telephone*
Is this telephone # a cell phone?*
- YES
- NO
Are you currently authorized to work in the United States? Proof of eligibility will be required if hired.*
- YES
- NO
Position applied for*
Desired hourly wage*

Availability
Do you have a preference for the days/hours you are available to work?*
- YES
- NO
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
How many hours can you work weekly?*
Employment desired*
- Full-time only
- Part-time only
When are you available to start work?*
MM slash DD slash YYYY
Upload Your Resume
Upload your resume in .pdf or .doc format
Accepted file types: pdf, doc, Max. file size: 25 MB.

Education
High School Name
High School Location
High School Major & Degree
College Name
College Location
College Major & Degree
Bus. or Trade School Name
Bus. or Trade School Location
Bus. or Trade School Major & Degree
Professional School Name
Professional School Location
Professional School Major & Degree

Military Experience
Have you ever been in the armed forces?*
- YES
- NO
Are you now a member in the armed forces?*
- YES
- NO
Specialty*
Date Entered*
MM slash DD slash YYYY
Discharge Date*
MM slash DD slash YYYY

Work Experience
Please list your work experience for the beginning with your most recent job held. If you were self-employed, give firm name.
How many past jobs would you like to include?*
- 1
- 2
- 3
- 4
Name of Employer
Address
Street Address City State ZIP Code
Phone
Name of last supervisor
First Last
Employment Date Start
MM slash DD slash YYYY
Employment Date End
MM slash DD slash YYYY
Your last job title with this employer
Job Duties
Reason for leaving (be specific)
Name of Employer
Address
Street Address City State ZIP Code
Phone
Name of last supervisor
First Last
Employment Date Start
MM slash DD slash YYYY
Employment Date End
MM slash DD slash YYYY
Your last job title with this employer
Job Duties
Reason for leaving (be specific)
Name of Employer
Address
Street Address City State ZIP Code
Phone
Name of last supervisor
First Last
Employment Date Start
MM slash DD slash YYYY
Employment Date End
MM slash DD slash YYYY
Your last job title with this employer
Job Duties
Reason for leaving (be specific)
Name of Employer
Address
Street Address City State ZIP Code
Phone
Name of last supervisor
First Last
Employment Date Start
MM slash DD slash YYYY
Employment Date End
MM slash DD slash YYYY
Your last job title with this employer
Job Duties
Reason for leaving (be specific)
May we contact your present employer?*
- YES
- NO
If no, why not?*
After reviewing the attached job description, please indicate if you are able to perform the essential functions of the job for which you have applied, with or without a reasonable accommodation*
- YES
- NO
Do you have an employee referral?*
- YES
- NO
Employee Referral

Please Read Carefully
Consent*
I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.
We are an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, age, height, weight, or disability. We assure you that your opportunity for employment with us depends solely on your qualifications. Thank you for completing this application form and for your interest in our business.
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Email
Phone
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ADDRESS
VIC the PICC
1351 E. Pine Street, Suite F
Lodi CA 95240

PHONE
Main: 866-971-8422
Fax: 888-723-8422

ASSOCIATIONS

Contact Us

Name*
Department*
Email*
Phone*
Message*
Consent*
*
I agree that VIC the PICC may contact me by telephone (including cell phones), facsimile, email, SMS or other internet facilities, with respect to employment, education, services, training and other offerings we may make available in the future. Voice and data rates may apply.
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Email
This field is for validation purposes and should be left unchanged.

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