Thank you for your interest in working with DREAM Wellness as an Associate Doctor of Chiropractic! Please complete the application below and we will get back to you shortly. Name* First Last Email* Best Phone to Reach You:*Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Place of Birth:*Describe how you live a healthy, "wellness" lifestyle:*EducationThis information is necessary for the proper background checksHigh School Attended (location and years)*College Attended & Degree Earned (include location and years attended)*Chiropractic College Attended (location and years)*What special degrees, honors or certifications (if any) did you earn from chiropractic college? (Type none if not applicable)*What special certifications, degrees or diplomates (if any) do you curently hold? (Type none if not applicable)*Work History (most recent job)*Additional Work History, previous jobs, etc....Practice History (actual work as a DC)*List preference of adjusting techniques:*Describe the practice of your dreams (techniques, philosophy, clientele, cash/insurance, etc...):*What are your goals in chiropractic?*What are your strongest points in the doctor/practice member relationship?*In what areas do you need the most growth?*Do you have any restrictions on times that you can work in the office? (If yes, explain)*If hired, how soon would you able to begin working at DREAM Wellness?*If hired, when would be the BEST day for YOU to begin employment at DREAM Wellness? (I understand that in some cases, willingness and convenience don't always coincide)*Are you willing to work at least 2 hours over the weekend?* Yes No What is the minumum income you require to meet your needs?*What would you like to earn this year?*What do you hope to gain by being a part of DREAM Wellness?*I am looking to join the DREAM Wellness team as:* A) An associate doctor with a salary only B) An independent contractor doctor and pay the practice a percentage of my income only C) A doctor of chiropractic as a renter only D) I would entertain being a combination of A & B (Associate & Percentage) E) I would entertain being a combination of A & C (Associate & Renter) What would be the ideal situation for you?*References, etc...Please list 5 references, mixing personal and professional. Include their name, your affiliation with him/her and a phone number. (Only one can be family)*Please list any coaching, consulting or seminar groups that you have been a part of during chiropractic school or as a doctor. Include the things you liked most and least about them.*Have you ever been convicted of a felony?* Yes No Attach your resume / CV here if applicable (PDF please) Drop files here or Select files Max. file size: 1 GB. Digital Signature*PLEASE READ CAREFULLY BEFORE SIGNING APPLICATION I have submitted the attached form to the company for the purpose of obtaining employment. I acknowledge that the use of this form, and my filling it out, does not indicate that any positions are open, nor does it obligate the company to further process my application. My signature below attests to the fact that the information that I have provided on my application, resume, given verbally, or provided in any other materials, is true and complete to the best of my knowledge and also constitutes authority to verify any and all information submitted on this application. I understand that any misrepresentation or omission of any fact in my application, resume or any other materials, or during any interviews, can be justification for refusal of employment, or, if employed, termination from the Company’s employ. I also affirm that I have not signed any kind of restrictive document creating any obligation to any former employer that would restrict my acceptance of employment with the Company in the position I am seeking. I understand that this application is not an employment contract for any specific length of time between the Company and me, and that in the event I am hired, my employment will be “at will” and either the Company or I can terminate my employment with or without cause and with or without notice at any time. Nothing contained in any handbook, manual, policy and the like, distributed by the Company to its employees is intended to or can create an employment contract, an offer of employment or any obligation on the Company’s part. The Company may, at its sole discretion, hold in abeyance or revoke, amend or modify, abridge or change any benefit, policy practice, condition or process affecting its employees. References: I hereby authorize the company and its agents to make such investigations and inquiries into my employment and educational history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, and other persons from all liability in responding to inquires connected with my application and I specifically authorize the release of information by any schools, businesses, individuals, services or other entities listed by me in this form. Furthermore, I authorize the company and its agents to release any reference information to clients who request such information for purposes of evaluating my credentials and qualifications. Temporary/Contract Employment: If employed as a temporary or contract employee, I understand that I may be an employee of the company and not of any client. If employed, I further understand that my employment is not guaranteed for any specific time and may be terminated at any time for any reason. I further understand that a contract will exist between the company and each client to whom I may be assigned which will require the client to pay a fee to the company in the event that I accept direct employment with the client, I agree to notify the company immediately should I be offered direct employment by a client (or by referral of the client to any subsidiary or affiliated company), either for a permanent, temporary (including assignments through another agency), or consulting positions during my assignment or after my assignment has ended. First Last Date* Δ