ARIZONA SKIN CANCER SURGERY CENTER, P.C.
MICHAEL J. HUETHER, M.D., P.C.

APPLICATION FOR EMPLOYMENT

Phone

Address

EXPERIENCE AND SKILLS
Have you had experience in the following?

EDUCATION

COLLEGE, TRADE SCHOOL OR SPECIAL TRAINING

MEDICAL CERTIFICATES OR LICENSES


1. PREVIOUS EMPLOYMENT List present or most recent position first.
Please cover the last 10 years of employment. Explain gaps in employment of > 30 days.


2. PREVIOUS EMPLOYMENT List present or most recent position first.
Please cover the last 10 years of employment. Explain gaps in employment of > 30 days.


3. PREVIOUS EMPLOYMENT List present or most recent position first.
Please cover the last 10 years of employment. Explain gaps in employment of > 30 days.


4. PREVIOUS EMPLOYMENT List present or most recent position first.
Please cover the last 10 years of employment. Explain gaps in employment of > 30 days.


I understand that and agree that if I am offered employment by Michael J. Huether, M.D., P.C., or by Arizona Skin Cancer Surgery Center, P.C. my employment will be for no definite term and that either I, or Michael J. Huether, M.D., P.C., or Arizona Skin Cancer Surgery Center, P.C. will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice.

I certify that the information in this application and in submitted resumes is true and complete for all practical purposes. I understand that misrepresentation or omissions of facts may result in termination of employment or censure, should I become an employee of Michael J. Huether, M.D., P.C., or Arizona Skin Cancer Surgery Center, P.C.. I hereby authorize Michael J. Huether, M.D., P.C., or Arizona Skin Cancer Surgery Center, P.C. to thoroughly investigate my background, references, employment record and other matters related to my suitability for employment. I authorize persons, schools, my current employer (if applicable), and previous employers and organizations contacted by Michael J. Huether, M.D., P.C., or Arizona Skin Cancer Surgery Center, P.C. to provide any relevant information regarding my current and/or previous employment and I release all persons, schools, employers of any and all claims for providing such information. I understand that nothing contained in this application, or conveyed during any interview which may be granted, is intended to create an employment contract. I understand that filling out this form does not guarantee that there is a position open and does not obligate Michael J. Huether, M.D., P.C., or Arizona Skin Cancer Surgery Center, P.C. to hire me. I also hereby certify that I am not currently excluded, debarred or otherwise ineligible to participate in the Federal health care programs or in Federal procurement or no-procurement programs; nor have I been convicted of a criminal offense related to the provision of health care items or services. I understand that Michael J. Huether, M.D., P.C., and Arizona Skin Cancer Surgery Center, P.C. reserve the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought in to or taken out of the facility. I understand that refusal to submit to these tests or searches, when requested to do so, may result in termination of my employment.