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. Your 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.)
Criminal History Details
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.
Employment Status Desired
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
Starting with your current or most recent, list all employers past and present. Include self-employment and summer and part-time jobs.
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.
. Other History
Certificates and Licenses
Provide details of any professional certifications or licenses.
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.
. Additional Details
Upload Your CV/Resume
If you have not already done so, please upload your cv/resume below.
Upload any additional attachments including cover letter, certifications, etc.
Has your license, DEA registration, certification, hospital privileges, or authorization to practice your profession ever been denied, restricted, suspended, not renewed, revoked, voluntarily relinquished, or been subject to investigation, review, reprimand, warning or any disciplinary action or probationary condition?
Have there been or are there currently pending, any malpractice suits, claims of injury, settlements or arbitration proceedings involving your professional practice? If yes, further information will be requested during the credentialing process.
Have you ever been convicted of a criminal offense? Any case will be judged on its own merit with respect to its effect on your professional qualifications and competence.
Has your professional employment or association with a professional organization, including training, ever been subject to disciplinary proceedings, denied, limited, restricted, reduced, suspended, revoked, not renewed, voluntarily relinquished during or under threat of termination, or terminated for any reason?
What is your desired geographic area of Atlanta? Please either list the areas in which you would like to work or put no preference.
Please provide an explanation for any gaps of more than 60 days in your education, training, or work history.
Are there any circumstances that may affect your ability to fulfill the responsibilities typically associated with the position for which you are applying?
Do you have a non-compete clause in your current employment contract?
If Yes, please be prepared to provide details to the recruiter.
Are you currently certified? If not, please explain.
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).
. Review and Submit
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.
Please review the information above before signing this application.
Candidate eSignature Date