TSPMG

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Adolescent Intensive Outpatient Program Group Facilitator
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Your Information

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Contact Information

(MD, DO, PhD, CNM, etc)

Criminal History Details

When completing this section, do not disclose information regarding convictions that have been judicially sealed, expunged, eradicated, impounded, or dismissed. Do not disclose information regarding juvenile court convictions or minor traffic violations. A conviction record does not automatically bar you from employment. All of the job-related circumstances surrounding convictions will be considered.
Have you since your 18th birthday been convicted or pled guilty to a felony or misdemeanor?

If you answered YES to any of the questions above, please explain below. If yes, list dates, location (city, state & country), violation(s) and outcome below. Includes all criminal laws (i.e. petty misdemeanors, misdemeanors, gross misdemeanors, felonies, ordinance violations, DWI/DUI/BW, etc.)

Additional Information

How did you hear about this opportunity?

Have you previously been employed with The Southeast Permanente Medical Group Inc. or another Kaiser entity?

Have you previously completed an application with The Southeast Permanente Medical Group Inc.?

Above, please identify only the name and job title of any relatives currently employed with The Southeast Permanente Medical Group Inc.

Are you currently employed?

List all methods, techniques, equipment and computer software applications with whcih you are proficient and which are relevant to the job for which you are applying.

Describe present and past memberships in professional organizations, including offices held (you may exclude memberships which suggest or disclose your race, color, national origin, religion, disability or any other protected status).

List published articles/research of work-related nature.

Work and Education History

Employment History

Starting with your current or most recent, list all employers past and present. Include self-employment and summer and part-time jobs.

Base Pay Annually

Base Pay Annually

Shift Premium, Bonus, Etc.

Describe any significant job-related accomplishments below. 

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Education/Training History

Describe any education or training using the fields below. Include High School, College or University, Graduate or Professional School, Trade or Business School, as well as any specialty or vocational training.

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Other History

Certificates and Licenses

Provide details of any professional certifications or licenses.

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References

List current and former co-workers, colleagues and/or professional acquaintances not related to you (other than those persons previously listed) who can provide first hand knowledge of your qualifications and abilities. The Southeast Permanente Medical Group, Inc. may contact these references in connection with its consideration of your credentials.

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Additional Details

Upload Your CV/Resume

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Additional Attachments

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Questions

Describe any other experiences (e.g. volunteer work), qualifications, skills or abilities which you possess in addition to those outlined on the previous page and which you consider important to the successful performance of the job for which you are applying (you may exclude any experiences which suggest or disclose your race, color, national origin, religion, disability, or other protected status).

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Submission

Applicant's Certification, Authorization, and Understanding

I certify the answers given herein are true and complete to the best of my knowledge, and I authorize the investigation of all statements contained within this employment application that may be necessary in arriving at an employment decision.  I further understand that, in the event of my employment by The Southeast Permanente Medical Group, Inc., any false or misleading information given in my application or interview(s) may result in discharge.  I also  understand that if employed by The Southeast Permanente Medical Group Inc., I will be required to abide by all company rules and regulations. 

I understand that any employment offer that may be extended to me by The Southeast Permanente Medical Group, Inc. is contingent upon my ability to satisfy the physical and mental requirements for the position offered, which may require me to submit to a drug/alcohol screening test and physical examination.

I understand this application and any subsequent offer of employment I may receive from The Southeast Permanente Medical Group, Inc. does not, and is not intended to, create a contract of employment or any contractual rights in favor of The Southeast Permanente Medical Group, Inc. or me beyond those existing in an at will employment relationship unless provided otherwise by an applicable collective bargaining agreement.  I understand that any employment relationship which may arise between The Southeast Permanente Medical Group, Inc. and me will be an at will relationship, which means The Southeast Permanente Medical Group, Inc. reserves the right to change, modify, suspend, revoke, or terminate my employment at any time, with or without reason, and with or without notice, and that I likewise have the right to terminate my employment with The Southeast Permanente Medical Group, Inc. at any time, with or without notice.

 

Candidate Signature

Please review the information above before signing this application.

Application Review