Online Application

1. Are you at least 18 years old?

   Yes No
2. Position(s) you are applying for:
3. Date available:
4. Pay expected: per: Hour Year
5. Work Area Preferred:

6. Are you willing to substitute at another location?

   Yes No
7. Days/shift desired:

8. Type of employment desired:

   Full Time Part Time Temporary

9. Are you willing to work weekends and holidays?

   Yes No

10. Have you ever been convicted of a felony?

    Yes No
11. If yes, date and nature of conviction:

1. List any relatives who work for Lexington Women's Health:

2. Type of School	Dates Attended	School Name/City	Graduate?	Major/Course	Degree Received
   High School
   College
   Graduate
   Other

3. List any professional license, certification, and/or registration you possess:
4. States where registered:
5. Expiration Date:

6. Has your professional license, certification, and/or registration ever been suspended or revoked?

   Yes No
7. If yes, why?

8. Do you authorize us to inquire about your licensure, certification, and/or registration with the appropriate licensing agency or board?

   Yes No

9. Employment History

   Employer	Address	Phone	Supervisor	Dates	Job Title	Ending Salary	Reason for Leaving

10. May we contact the employers you listed?

    Yes No
11. If No, Explain?
12. Explain any periods of unemployment during the past five years:

13. Have you ever served in the U.S. Armed Forces?

    Yes No
14. If Yes, which Branch?
15. List any other skills, training, or qualifications, not yet mentioned, which you think would benefit this organization:

16. List below two 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

I agree that:

I consent to all medical examinations and tests required by Lexington Women's Health, PLLC:

I release from liability all representatives of Lexington Women's Health, PLLC for any acts performed in good faith and without malice in connection with evaluating my application, competence, credentials, character, and qualifications and I release from liability any and all individuals and organizations who provide information to Lexington Women's Health, PLLC, in good faith and without malice, concerning my professional competence, credentials, character and other qualifications and I consent to the release of such information.

I understand that:

Lexington Women's Health, PLLC adheres to the "Employment at Will" doctrine that has been recognized by Kentucky courts. Under this doctrine, I am free, or the company is free to terminate my employment relationship at any time and for any reason.

I understand that the needs of Lexington Women's Health, PLLC may make overtime, shift work, a rotating work schedule, or a work schedule other than a standard schedule a mandatory condition of my employment. I also understand, upon termination of my employment, I must return any Company property issued to me or I will authorize the value of same to be deducted from my wages.

If employed, I understand that my employment is not guaranteed for a definite period of time. If my employment is terminated in the future, I understand that the Company is liable for my wages earned as of the date of my termination.

All statements made by the applicant on this application form will be checked for accuracy. Lexington Women's Health, PLLC offers equal employment opportunities to all persons without regard to race, color, religion, age, sex, national origin, or disability.

I certify that the information provided by me on this application is true to the best of my knowledge. Any false statements may result in termination of my employment.