DPC Management, LLC is an Equal Opportunity Employer. It is our policy to abide by all Federal and State laws prohibiting employment discrimination solely on the basis of a person’s race, color, creed, national origin, religion, age, sex, marital status, or physical or mental disability, except where a reasonable, bona fide occupational qualification exists.

Please type or print in ink. A copy of your driver’s license and Social Security card or Alien Registration must accompany this application.

General Information

Name

Street

How long In the current address?

City

State/Zip

Cell Phone

Home Phone

Email Address

Position Desired

Employment Type
Full TimePart TimeTemporary

Driver’s License

State

Expiration Date

Date of Birth

Salary Requirement

Are you at least 25 years of age?
YesNo

Do you have any commitments with another employer that might affect employment with us?

Personal References

Reference 1: Name

Occupation

Phone

Reference 2: Name

Occupation

Phone

Reference 3: Name

Occupation

Phone

Emergency Contact

Person to be notified in case of emergency: Name/Relationship

Emergency Phone

Emergency Contact Address

Other Information

Please list any equipment and/or software you are proficient with

Please include any other information you think would be helpful to us in considering you for employment

CV/Resume (Optional)

Agreement

I hereby affirm that the information provided on this application or resume is true and complete to the best of my knowledge. I also agree that if 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 authorize all persons listed above (and on the accompanying resume, if any) to give DPC any and all information concerning my previous employment and education and any pertinent information they may have, personal or otherwise, and release all parties or such persons and DPC from liability for any damage that may result from furnishing same to DPC.
I understand that DPC will provide workers’ compensation insurance coverage for its employees. In the event of any injury in the workplace, I agree that my sole remedy lies in coverage under DPC’s workers’ compensation insurance policy.
If employed by DPC, I agree to conform to the policies of DPC. I further understand that my employment can be terminated, with or without cause of notice, at any time, at the discretion of DPC or myself.
I understand and agree that I may be required to take drug and alcohol screening test prior to hire or during employment. I hereby give my voluntary consent for a blood and/or urine sample to be collected from and submitted for testing. I also consent to the release of the test result to DPC for its use. I understand that any possible drug or alcohol may preclude my employment.