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Applicant Information

* = Required
*Name: (last), (first) (middle)
*Social Security Number:
*Street Address:
Email Address:
*Primary Phone #:
Secondary Phone #:
Are you at least 16 years old?
Are you a citizen of the U.S. or otherwise lawfully authorized to work in the U.S.?
Have you ever been convicted of a felony? Convictions do not automatically disqualify an applicant from employment. The type and seriousness of the crime, the frequency of violations, the applicant’s age at the time of the conviction, and the date of conviction or time elapsed since the conviction or completion of any jail sentence will be taken into consideration in addition to other job-related criteria.

Position/Job Information

* = Required
*Position(s) Desired:
*Date Available:
*Expected Rate of Pay:
Shift Choices:   Are you willing to rotate shifts?
How did you hear about this position?
Name and relationship of any relative employed at Brown Clinic:
Have you been previously employed by Brown Clinic?
List any additional names which you have used in the past that will allow us to check your work record:
May your application be released to local clinics provided they have any openings in your area of interest?

Education/Skills Data

No Required Fields
Do you possess a high school diploma or GED?   Last Grade Completed:
Post-Secondary Education:
Did you graduate?
Add Another College or University
List all relevant professional licenses, registrations, or certifications you possess:

Add Another License/Permit/Certification

Legal Compliance

Have you ever been excluded from participation in the Medicare program?

Professional Referenences


Add Another Professional Reference

Employment History

May We Contact?

May We Contact?

May We Contact?

Add Another Previous Employer

Applicant Certification and Release of Information

(Please Read Carefully)


I hereby certify that all of the information provided by me in this application (or any accompanying documents) is correct, accurate and complete to the best of my knowledge. I understand that falsification and/or misrepresentation will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I hereby authorize Brown Clinic to investigate my statements and conduct a background investigation if deemed necessary. All employers, educational institutions, law enforcement agencies, state and federal courts, and references listed are hereby authorized to give Brown Clinic any and all information regarding my employment, background, or character. Brown Clinic and all employers, educational institutions, law enforcement agencies, state and federal courts, and references are herby released from any and all liability which may result from furnishing or using such information.

In consideration for employment with Brown Clinic, if employed, I agree to conform to the rules, regulations, policies and procedures of Brown Clinic at all times and understand that such obedience is a condition of employment. I understand that if offered a position with Brown conic, I will be required to submit to a pre-employment health assessment and background check as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of the pre-employment assessment and/or background check will result in a withdrawal of any employment offer or termination of employment if already employed.

The use of this application does not indicate there are positions open and does not in any way obligate Brown Clinic. Additionally, this application should not be considered as an employment agreement. Any decisions regarding length of employment, interpretation, or application of policies or procedures by the Clinic will be final and binding on all parties concerned. I further agree that my employment and compensation can be terminated at will, with or without cause and with or without notice, at anytime either at my option or at the option of Brown Clinic.

  I Agree to all Terms of certification and relase of Information