Ken Langley, M.D., F.A.C.S.

Ken Langley, M.D., F.A.C.S. APPLICATION FOR EMPLOYMENT All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law. PERSONAL INFORMATION Date Name (Last, First, Middle) Social Security # Present Address (Street, City, State, Zip) Telephone # Email Address Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Yes No If yes, explain: Type of employment desired: Full-Time Part-Time Temporary Days/Hours Available (circle) MON TUE WED THU FRI SAT SUN AM PM Can you work overtime if necessary? Yes No Have you ever worked for this company before? Yes No If yes, when and under what name? Position applying for: Salary Desired: EDUCATION School Name Location (City/State) Course of Study # Years Completed Diploma/Degree High School College/University Other SKILLS Please list any special skills and qualifications you possess: REFERENCES Please list three professional references. DO NOT include relatives. Name Complete Address Telephone # Occupation # Years Known EMPLOYMENT HISTORY List your current and/or previous employers, starting with the most recent. Account for all periods of time, including military service and any periods of unemployment. Employer Address Job Title Dates Employed Starting Salary Ending Salary Reason for Leaving May we contact? Yes No Employer Address Job Title Dates Employed Starting Salary Ending Salary Reason for Leaving May we contact? Yes No Employer Address Job Title Dates Employed Starting Salary Ending Salary Reason for Leaving May we contact? Yes No Have you ever been convicted of a crime? Yes No If yes, please explain: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ACKNOWLEDGEMENT AND AUTHORIZATION I certify that all the statements made by me in this application are true and correct to the best of my knowledge and belief, and I understand that any misrepresentation or omission of facts shall be cause for my dismissal at any time without prior notice. I authorize the company to investigate all statements contained in this application and/or made during the interview process, and to contact any of the references listed in this application. I further authorize my previous employers and references to give the company any information or opinion concerning my previous employment or qualifications. I understand and agree that if I am hired, my employment with the company is for no definite period of time, and may be terminated at any time, with or without cause, and with or without notice. I understand that this application is considered current for thirty (30) days. If I wish to be considered for employment after this period, I must fill out and submit a new application. Signature of Applicant Date Ken Langley, M.D., F.A.C.S. 2200 S.E. Veterans Memorial Hwy. Port St. Lucie, FL 34952