Careers

Employment Application

An Equal Employment Opportunity Employer. We comply with all applicable State and Federal Civil Rights and Equal Employment Laws and Regulations.

In considering your application for employment, the facility may conduct a detailed and thorough investigation which may include but is not limited to a criminal record check, interviews or inquiries of prior employers, coworkers, acquaintances, relatives or friends.

* Indicates REQUIRED FIELD

Personal

Last Name*	First*	Middle
Present Address	City	State	Zip
Permanent Address	City	State	Zip
Email Address*
Any previous name(s) Yes No If yes, please identify all other names including maiden name.

Home Telephone Number
Contact Telephone Number
Best Time to Contact You	Date Available For Work
Are you applying for
Full Time Regular	Part Time Temporary

Position Applied For
How were you referred to this facility?
Do you have relatives or friends employed in this facility? Yes No
Name	Department	Relationship
Have you ever been employed by this facility? Yes No If yes, when?		Are you 18 years of age or older? Yes No
Long Range Occupational Goals
Have you ever been convicted of, or plead guilty to a crime (excluding misdemeanor traffic violations)? Yes No If yes, please explain. If your answer is "Yes," you will not automatically be disqualified from employment consideration, except as required by State or Federal Law.

Salary Desired
Would you consider working
Weekends/Holidays	Yes No
Rotating Shifts	Yes No
On Call	Yes No
Any Shift	Yes No
Shift Preference Days Evenings Nights
Are you a U.S. Citizen or an Alien legally authorized to work in the United States? Yes No

Education / Skills
Name / Address	Course of Study	Last Year Completed		Did You Graduate	List Diploma or Degree
High School Address		1 2	3 4	Yes No
College Address		1 2	3 4	Yes No
College Address		1 2	3 4	Yes No
Other Business College, Other Special Courses (Include Special Military Training, Post Graduate and Nursing)
Area of Specialization or Major Interest	Typing: Approx. WPM			Shorthand: Approx. WPM
List Health Care, Business or Industrial Equipment Operated

Professional Licenses
Currently Licensed Currently Registered Eligible for License Eligible for Registration	License or Registration EVER Suspended, Revoked or on Probation? Yes No If Yes, Explain
Type	State	Date	No
Currently Licensed Currently Registered Eligible for License Eligible for Registration	License or Registration EVER Suspended, Revoked or on Probation? Yes No If Yes, Explain
Type	State	Date	No

Professional Certifications
Currently Certified Eligible for Certification
Type	State	Date
Currently Certified Eligible for Certification
Type	State	Date

Language Skills
Language	Do You?	Speak	Fair Good Fluent	Read	Fair Good Fluent	Write	Fair Good Fluent
Language	Do You?	Speak	Fair Good Fluent	Read	Fair Good Fluent	Write	Fair Good Fluent

Previous Experience
Provide information regarding previous employment beginning with the most recent

Job Title	From	To	Supervisor's Name	Salary (Hr/Mo/Yr)
Employer			Phone
Address
Duties
Reason for Leaving

Job Title	From	To	Supervisor's Name	Salary (Hr/Mo/Yr)
Employer			Phone
Address
Duties
Reason for Leaving

Job Title	From	To	Supervisor's Name	Salary (Hr/Mo/Yr)
Employer			Phone
Address
Duties
Reason for Leaving

Job Title	From	To	Supervisor's Name	Salary (Hr/Mo/Yr)
Employer			Phone
Address
Duties
Reason for Leaving

Please identify and explain any gaps in employment longer than three (3) months.

Did you serve in the U.S. Armed Services?	Yes No	What Branch?
Have you volunteered your time or services?	Yes No	Where?
Briefly describe duties and skills acquired through volunteer or military service (include dates).

References
List at least three (3) references who are not relatives or employers.

Name / Relationship	Title	Company / Address	Phone

Signature

CAREFULLY READ THIS SECTION PRIOR TO PROVIDING SIGNATURE BELOW

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.

I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment.

I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information.

I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.

Date

Signature* (REQUIRED FIELD)

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Careers

Employment Application

Personal

Education / Skills

Professional Licenses

Professional Certifications

Language Skills

Previous Experience

References

Signature