Lexington Women’s Health, PLLC
1720 Nicholasville Road Ste 702
Lexington, KY 40503
Phone (859)264-8811
Fax(859) 264-8822


PERSONAL INFORMATION

*First Name
First Name is required.		 *Last Name
Last Name is required.
Middle Name *SS#
SS# is required.
*Address
Address is required.		 Address2
*City
City is required.		 *State
Please select your State.

 *Zip
Zip Code is required.
*E-mail
Email is required.		 *Home Phone
Phone Number is required.
Are you at least 18 years old? YES NO
Position(s) you are applying for:
Date available for work: Pay expected        per
Work area preferred:     Days/shift desired:
Type of employment desired:
Full time   Part time   Temporary  
Are you willing to work weekends and holidays?
YES   NO  
Have you ever been convicted of a felony?
YES   NO  
If yes, date and nature of conviction:
Are you willing to substitute at another location?
YES   NO  
List any relatives who work for Lexington Women’s Health:
Type of School Dates Attended School Name/City Graduate? Major/Course Degree Received
High
College
Graduate
Other
List any professional license, certification, and/or registration you possess:
States where registered: Expiration Date:
Has your professional license, certification, and/or registration ever been suspended or revoked?
YES   NO  
If yes, why?
Do you authorize us to inquire about your licensure, certification, and/or registration with the appropriate licensing agency or board?
YES   NO  
Employer Name/Address/Phone/Supervisor's Name Dates of Employment Job Title and Duties Ending Salary Reason for Leaving
May we contact the employers you listed?
YES   NO  
If No, Expalin?
Explain any periods of unemployment during the past five years:
Have you ever served in the U.S. Armed Forces?
YES   NO  
If Yes, which Branch?
List any other skills, training, or qualifications, not yet mentioned, which you think would benefit this organization:

List below three people we can call as references for you. These need to be work related, not family or friends.

Reference Name How you know this reference Reference Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lexington Women’s Health is comprised of four board certified obstetrician-gynecologists supported by an experienced and well trained team of medical professionals. Emily Cunningham, M.D., Jennifer Fuson M.D. FACOG, Joanne O’Nan M.D., Leah Mitchell M.D., Melissa Courtney ARNP., Kethryn Allen, PAC, Laure Schadler C.N.M., and Crystal Brown, ARNP make up the medical staff of Lexington Women’s Health located at 1720 Nicholasville Rd., Suite 702 Lexington Kentucky. If you are looking for an obstetrician or gynecologists in the Lexington Kentucky area contact Lexington Women’s Health to schedule an appointment with either Dr. Cunningham, Dr. Fuson, Dr O’Nan or Dr. Mitchell today.