Employment Form

Are you willing to work

Overtime (over 40 hrs./wk.) *
On-call *
Rotating Shifts *
Nights *
Weekends (Sat./Sun.) *
Holidays *
Travel *

Indicate applicable work skills

Are you applying for *
Have you ever been employed by this organization?
Type Name/Address Course of Study Circle last year completed Did you graduate? Diploma/Degree
High School
Technical,Business or Professional

Professional Licenses/Certifications

Type State Exp. Date Registration Number

Please list name, address, and phone number of previous employers with most recent employer first. Periods of unemployment should be included.

From To Immediate Supervisor Last Salary- Hourly, Monthly, or Yearly
From To Immediate Supervisor Last Salary- Hourly, Monthly, or Yearly
From To Immediate Supervisor Last Salary- Hourly, Monthly, or Yearly
May we run an employment check from the employers listed above?
Has notice been given to present employer?
Please list references (not relatives or employers) to contact who are acquainted with your work history.
Name Title/Occupation Company/Address Phone Number
I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. I understand that my employment can be terminated, with or without cause, at any time at the discretion of the employer or myself. I understand that no management official of the employer other than the chief executive officer of the employer has any authority to enter into any agreement contrary to the foregoing or to make any oral assurance or promise of continued employment to me. I authorize and hold free from liability any persons, schools, my current employer (if applicable) and previous employers and organizations named in this application (and accompanying resume, if any) to provide any relevant information that may be required to arrive at an employment decision.
NOTE: All offers contingent upon the successful completion of references, background checks, pre-employment physical, and drug screen.

Specialty care close to home

Up-to-date. Down-to-earth. Close to home. Lots of great reasons to make Mason City Clinic
your first choice for all your family’s specialty healthcare needs.

250 S. Crescent Drive, Mason City, IA 50401

Tel: 641.494.5200

Toll Free: 800-622-1411

Fax: 641.494.5403

Driving Directions

2440 Bridge Avenue, Albert Lea, MN 56007

Tel: 641.494.5200

Fax: 641.494.5403

Driving Directions