Hit enter to search or ESC to close

About Us
- F.A.Q.
- Commonly Requested Forms
Services
Providers
Locations
Contact Us
more…

F.M.C. EMPLOYMENT APPLICATION

Family MedCenters, P.A. is an equal opportunity employer. Applicants are considered for all positions without regard to race, color, religion, gender, national origin, age, sexual orientation, marital or veteran status, medical condition or handicap, or any other legally protected status.

EMPLOYMENT APPLICATION

- Step 1 of 8

Personal Information:

First Name *

M.I.

Last Name *

Date of Birth *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Home Phone

Cell Phone *

For your protection Family MedCenters, P.A. will never ask you to submit your social security number online.

If under 18 years of age, can you provide required proof of your eligibility to work? *

Are you a veteran of the armed forces? *

Do you have a valid Driver's License? *

Are you legally eligible for employment in this country? *

Proof of citizenship or the right to work in the U.S. will be required upon employment.

Have you ever been convicted of a crime? (Do not include arrests or non-convictions) *

Conviction will not necessarily disqualify an applicant from employment.

If you answered "Yes" to the above question, please list all convictions, including misdemeanors and/or felonies in the space provided below:

Position(s) Applied For:

Select One or Multiple *

Certified Medical Assistant (Rose Hill)
Referrals Specialist (Rose Hill)
Certified Medical Lab Personnel (Derby)
Medical Receptionist (Derby)
Certified Medical Assistant (Southeast Wichita)
Certified Medical Assistant (Mulvane)

High School Education:

High School Name *

Location *

City and state where school is located.

Diploma/Degree Earned? *

If yes, please answer the question labeled "Degree"

Diploma/Degree *

Use this space to list your Degree.

Dates Attended *

List the dates you attended this school using the following format: (MM/YYYY-MM/YYYY).

Honors/Additional Information

Please list any honors received while you were at this school and any additional information you would like to add regarding this specific school.

College/University (Undergraduate) Education:

College/University Name

Location

City and state where school is located.

Degree Earned?

If yes, please answer the question labeled "Degree"

Degree

Use this space to list your Degree.

Dates Attended

List the dates you attended this school using the following format: (MM/YYYY-MM/YYYY).

Honors/Additional Information

Please list any honors received while you were at this school and any additional information you would like to add regarding this specific school.

Graduate/Professional School:

Graduate/Professional School Name

Location

City and state where school is located.

Degree Earned?

If yes, please answer the question labeled "Degree"

Degree

Use this space to list your Degree.

Dates Attended

List the dates you attended this school using the following format: (MM/YYYY-MM/YYYY).

Honors/Additional Information

Please list any honors received while you were at this school and any additional information you would like to add regarding this specific school.

Previous Employment:

Please complete the information below, beginning with your present or most recent job. If you have no previous employment experience please list "N/A" in the fields marked as *Required below.

Company Name *

Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Supervisor *

Dates Employed *

May we contact your previous supervisor? *

Job Title *

Starting Salary

Ending Salary

Responsibilities/Duties *

Reason for Leaving *

Company Name

Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Supervisor

Dates Employed

List the dates you worked at this job using the following format: (MM/YYYY-MM/YYYY). IF you are currently working here type your start date as above followed by the word "present" (MM/YYYY-Present).

May we contact your previous supervisor?

Job Title

Starting Salary

Ending Salary

Responsibilities/Duties

Reason for Leaving

Company Name

Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Supervisor

Dates Employed

List the dates you worked at this job using the following format: (MM/YYYY-MM/YYYY). IF you are currently working here type your start date as above followed by the word "present" (MM/YYYY-Present).

May we contact your previous supervisor?

Job Title

Starting Salary

Ending Salary

Responsibilities/Duties

Reason for Leaving

Military Service:

Please complete the below section only if applicable, if not applicable please move on to the next section.

Branch

Dates Enlisted

List the date you were enlisted with the Armed Forces using the following format: (MM/YYYY-MM/YYYY). If you are currently enlisted type your start date as above followed by the word "present" (MM/YYYY-Present).

Rank at Discharge

Type of Discharge

If other than honorable, please explain.

Other Information:

Use the separate spaces below to list things like licenses/certificates, training, skills, and extracurricular activities.

Licenses / Certificates Earned:

Please list any licenses or certificates that you have earned or currently hold if applicable to the position you are applying for.

Specialized Training / Apprenticeship:

Please list any specialized training and / or apprenticeship you have received that you'd like to list on this application.

Specialized Training / Apprenticeship:

Please list any applicable skills you'd like added to this application.

Extracurricular Activities:

Please list any extracurricular activities you'd like to make us aware of and feel free to list any workshops or short courses taken using the space provided.

Document Upload:

Résumé / C.V. Upload

Click or drag a file to this area to upload.

Please upload a copy of your résumé or C.V. here, this uploader accepts multiple file formats. Maximum file size: 20MB

Cover Letter Upload

Click or drag a file to this area to upload.

Please upload a copy of your cover letter here, this uploader accepts multiple file formats. Maximum file size: 20MB

Applicant's Statement / Electronic Signature:

I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Family MedCenters, P.A. to verify their accuracy and to obtain reference information on my work performance. I hereby release Family MedCenters, P.A. from any/all liability of whatever kind of nature which, at any time, could result from obtaining and having an employment decision based on such information. I understand that, if employed, falsified statements of any kind of omissions of facts called for on this application may be sufficient basis for dismissal.

I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules, and regulations of employment of the Employer (Family MedCenters, P.A.). However, I further understand that neither the policies, rules, regulations of employment nor anything said during the interview process shall be deemed to constitute the terms of an implied employment contract.

I understand that any employment offered is for an indefinite duration and at will and that either I or the Employer (Family MedCenters, P.A.) may terminate my employment at any time with or without notice or cause.

Applicant's Name

Please type your first and last name in this box to act as your electronic signature.

Today's Date *

Electronic Signature *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above statement(s).

Quick Links

Contact Us
F.A.Q.
Services
Patient Portal
Pay Your Bill

Website Policies

Privacy Notice
Notice of Non-Discrimination
Terms of Service
Refund Policy
Regulatory Compliance

Looking for Urgent Care Info?
Click the button below:

Urgent Care

Close Menu

About Us
- F.A.Q.
- Commonly Requested Forms
Services
Providers
Locations
Contact Us
more…