Physician Biographies Office Information RX Refills & Appointment Requests Procedures Patient Education Patient Forms
Privacy Statement
Employment
Links
 
 
 
 
 
Employment Application
Application Information
First Name *
Last Name *
Email
Address *
City *
State *
Zipcode *
Daytime Phone *
Evening Phone
Social Security Number
not required
Position Applied For
Have you ever plead guilty, no contest, or been convicted of a crime? *
If you answered yes to the question above, please explain.
Employment History
Starting with your previous employer, please provide the following information.
Previous Employers Name *
Previous Employers Phone *
Job Title *
Time Employed * Years Months
Describe your responsibilities.
May we contact for reference? *
Previous Employers Name
Previous Employers Phone
Job Title
Time Employed Years Months
Describe your responsibilities.
May we contact for reference?
Skills
Summarize any special training, skills, licenses and or certificates that may assist you in performing the position for which you are applying.
Education
Starting with your most recent school attended, provide the following information.
Name of School *
Years Completed *
Completed? *
If you selected Degree, Certification, or Other, please describe.
Name of School
Years Completed
Completed?
If you selected Degree, Certification, or Other, please describe.
Name of School
Years Completed
Completed?
If you selected Degree, Certification, or Other, please describe.
References
List name and phone number of three business/work references who are not related to you.
Name *
Phone Number *
Relationship to you *
Years Known *
Name *
Phone Number *
Relationship to you *
Years Known *
Name *
Phone Number *
Relationship to you *
Years Known *
Application Statement

I hereby certify that this application contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge. I am aware that should investigation at any time disclose such misrepresentation or falsification, my application may be rejected, my name may be removed from consideration, or if employed, I may be discharged from my employment.

I authorize my current or former employers and all schools or educational and technical institutions which I have attended to provide Cardiology Associates of Norwich, LLC representatives any information regarding my current or former employment, scholastic records or ratings. I hereby release any such current or former employers or institutions, their agents or employees from any and all liability resulting from the release of such information. My authorization and release from liability are voluntary acts. This authorization shall be effective for employment investigations by Cardiology Associates of Norwich, LLC and/or its agents.

Further, I understand that at time of hire, I will be required to provide documentation showing authorization to work in the United States. I further authorize Cardiology Associates of Norwich, LLC to check my credit and/or driving history and/or criminal background. I consent to submit to drug testing as a condition of initial or, if hired, continued employment with Cardiology Associates of Norwich, LLC.

 

Cardiology Associates
of Norwich, LLC
79 Wawecus Street
Suite 106
Norwich, CT 06360

Phone:: 860•886•2679
Fax:: 860•889•2862