APPLICATION FORM

Incomplete information could disqualify you from further consideration. Please complete all fields.

Give the names of 3 persons not related to you, whom you have known for at least three (3) years.

Family Solutions Practice Management (FSPM) is an equal opportunity employer. FSPM does not discriminate in employment on account of race, color, religion, national origin, citizenship status, ancestry, age, sex, sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service. I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for FSPM to hire me. If I am hired, I understand that either FSPM or I can terminate my employment at anytime and for any reason, with or without cause and without prior notice. I understand that no representative of FSPM has the authority to make any assurance to the contrary. I attest with my signature below that I have given to FSPM true and complete information on this application. No requested information has been concealed. I authorize FSPM to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.