Privia Medical Group logo


Maryland ENT logo

2415 Musgrove Road, Suite 203
Silver Spring, Maryland 20904
(301) 989-2300
We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

Drug screen required prior to employment.
How did you learn about us?
Have you ever filed an application with us before?  
Have you ever been employed with us before?  
Are you currently employed?  
Are you prevented from lawfully becoming employed in this country because of visa or Immigration status?
Proof of citizenship or immigration status will be required upon employment.
Are you available to work?
Are you currently on “lay-off” status and subject to recall?
Have you been convicted of a felony within the last 7 years?
Conviction will not necessarily disqualify an applicant from employment.


Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations that indicate race, color, religion, gender, national origin, disabilities or other protected status.

  Add another



High School

Undergraduate College

Graduate Professional


Can you speak, read and/or write any foreign languages?


Additional Information

Other Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experience.
Specialized Skills
Check skills/equipment operated
Professional References


Applicant’s Statement

I certify that answers given herein are true and complete to the best of my knowledge. I understand that my employment is conditional on the results of my Drug Screening.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
Signature of Applicant – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
LuxSci helps ensure HIPAA-compliance for email and web services.