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Alexandria Clinic, P.A.

Application 610 30th Ave West
Alexandria, MN 56308-3403
for Employment Phone: (320) 763-5123

We consider applicants for all positions without regard to race, color, religion, creed, gender, national
origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.
(You may exclude information which indicates race, color, religion, gender, national origin, disabilities,
or other protected status.)

(PLEASE PRINT)
Position(s) Applied For Date of Application

How did you learn about us?

Advertisement Friend Walk-In
Employment Agency Relative Other _______________

Last Name First Name Middle Name

Address City State Zip Code

Telephone Number(s) Social Security Number

Email Address

Are you 18 years or older? Yes No

Have you ever filed an application with us before? Yes No
If Yes, give date ________________
Have you ever been employed with us before? Yes No
If Yes, give date ________________
Do you have a firm salary requirement? Yes No
I require $ ________________
Are you a citizen of the U.S.? Yes No
If not, are you permitted to work in the U.S.? Yes No
(You must be prepared to show proof of citizenship or eligibility to work in the U.S.)

On what date would you be available for work? ________________

Are you available to work: Full Time Part Time On Call Temporary
Have you ever been convicted of a felony or misdemeanor? Yes No
Conviction will not necessarily disqualify an applicant from employment.

If Yes, please describe in full, including dates ________________________________________

____________________________________________________________________________________
WE ARE AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER
Education Alexandria Clinic, P.A.

Name and location Years

Course of Study Diploma / Degree
of School Completed
High
School

Undergraduate
College

Graduate
Professional

Other
(Specify)

Are you presently attending school? Yes No

Purpose? ______________________________ School? _____________________________

Describe any specialized training, apprenticeship, skills, extra-curricular activities, academic

honors and offices held.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Describe any job-related training received in the United States military.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________
Employment Experience Alexandria Clinic, P.A.
Start with your most recent job. Include any job-related military assignments and volunteer activities.
Employer Telephone Number(s)

Address Supervisor’s Name and Title

List all titles or positions held Dates Employed

From To
Did you work full time, part time, or less than part time? Hourly Rate/Salary
Started Final
Reason for leaving: Did you or are you leaving voluntarily?
Yes___ No___
May we contact this employer for a reference? Yes___ No___
If not, state reason:
Most significant duties and responsibilities:

Employer Telephone Number(s)

Address Supervisor’s Name and Title

List all titles or positions held Dates Employed

From To
Did you work full time, part time, or less than part time? Hourly Rate/Salary
Started Final
Reason for leaving: Did you or are you leaving voluntarily?
Yes___ No___
May we contact this employer for a reference? Yes___ No___
If not, state reason:
Most significant duties and responsibilities:

Employer Telephone Number(s)

Address Supervisor’s Name and Title

List all titles or positions held Dates Employed

From To
Did you work full time, part time, or less than part time? Hourly Rate/Salary
Started Final
Reason for leaving: Did you or are you leaving voluntarily?
Yes___ No___
May we contact this employer for a reference? Yes___ No___
If not, state reason:
Most significant duties and responsibilities:
Additional Information Alexandria Clinic, P.A.

Other Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experience.

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

State any additional information you feel may be helpful to us in considering your application.

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

References
List THREE persons we may contact as to EMPLOYMENT or ACADEMIC BACKGROUND (i.e.,
teachers, professors, managers, supervisors)

Name ____________________________________ Company or School _________________________

Position/Relationship to you ____________________________________________________________
Address ____________________________________________________________________________
Telephone number to reach at ___________________________________________________________

Name ____________________________________ Company or School _________________________

Position/Relationship to you ____________________________________________________________
Address ____________________________________________________________________________
Telephone number to reach at ___________________________________________________________

Name ____________________________________ Company or School _________________________

Position/Relationship to you ____________________________________________________________
Address ____________________________________________________________________________
Telephone number to reach at ___________________________________________________________
Applicant’s Statement Alexandria Clinic, P.A.

I certify that all information I have provided in order to apply for and secure work with
the employer is true, complete, and correct. I understand that any information provided
by me that is found to be false, incomplete or misrepresented in any respect, will be
sufficient cause to (i) cancel further consideration of this application, or (ii) immediately
discharge me from the employer’s service, whenever it is discovered.

I voluntarily give the Alexandria Clinic the right to conduct a complete background
investigation and agree to cooperate in such investigation and release from all liability or
responsibility all persons, companies, or organizations supplying such information.

I understand that Alexandria Clinic retains the right to terminate its employees at any
time for any reason not prohibited by law and, if hired, I understand that I am free to
resign at any time for any reason, subject to Alexandria Clinic’s notice requirement and
that these mutual rights constitute Alexandria Clinic’s at will policy.

Furthermore, I understand no officer, management official, or employee is authorized to

make any oral assurance or promise regarding any condition of employment, including,
but not limited to, a promise of continued employment. I further acknowledged and
understand that, if I am employed, Alexandria Clinic has the right, at any time and for
any reason, to make changes in all employment policies, instructions and procedures,
with or without notice and that I am required to abide by all rules and regulations of the
Alexandria Clinic.

DO NOT SIGN UNTIL YOU HAVE READ

THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Signature of Applicant _________________________________________

Date __________________________________
Applicant/Employee
Voluntary Self-Identification Alexandria Clinic, P.A.

Position for which you are applying or current position: ___________________________

Alexandria Clinic, P.A. is an equal opportunity employer. The company is subject to certain
governmental recordkeeping and reporting requirements for the administration of civil rights laws and
regulations. To comply with these laws, we invite you to voluntarily self-identify your race or ethnicity.
Self-identification is voluntary and there will be no negative consequences if you elect not to disclose
this information. The information obtained well be kept confidential and will only be used in
accordance with the provisions of applicable laws, executive orders, and regulations. When reported,
the data will not identify any specific individual.

Please print legibly in blue or black ink.

First: _______________________ Middle: ______________________ Last: ___________________

City: ______________________________ State: _________________ Zip: ____________________

Current Work Site (if applicable): ________________________________________________________

Voluntary Information:
Male ____ Female ____

We invite you to voluntarily self identify yourself under these classifications:

Ethnicity:
White, not of Hispanic origin – includes persons of Middle Eastern descent;
Black or African American, not of Hispanic origin – includes persons having origins in Jamaica
and the West Indies;
Hispanic (All races) – includes persons having origins in Mexico, Puerto Rico, Cuba, Central or
South America or of Spanish culture or origins;
Asian or Pacific Islander – includes persons having origins in the Far East, Southeast Asia, the
Indian Subcontinent or the Pacific Islands;
American Indian or Alaskan Native (not Hispanic or Latino) – persons having origins in any of
the original peoples of North America who maintain a cultural identification through tribal
affiliation or community recognition
Decline to disclose