Employment Application

In considering your 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 employees, coworkers, acquaintances, relatives or friends.

GENERAL INFORMATION

Last Name

First Name

Middle

Present Address

City

State

Zip

Any Previous Name(s)? If no, please leave blank.

CONTACT INFORMATION

Phone

Email Address

Best time to contact you

Date available for work

SELECT ALL THAT YOU WOULD CONSIDER WORKING

Full Time / Regular

Weekends & Holiday Yes No

Full Time / Temporary

Rotating Shifts Yes No

Part Time / Regular

On Call Yes No

Part Time / Temporary

Any Shift Yes No

SHIFT AVAILABILITY

Days Evenings Nights

Position Applied for

Salary Desired

How did you hear about this job?

Have you ever been employed by this facility? Yes No When?

Long Range Occupational Goals

Are you a U.S. citizen or an alien legally authorized to work in the U.S.? Yes No

Are you 18+ years of age? Yes No

RELATIVES OR FRIENDS EMPLOYED IN THIS FACILITY?

Name

Department

Relationship

Have you ever been convicted of, or plead guilty to, a crime other than a misdemeanor traffic violation? Yes No If Yes, Explain

Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this state or any other state of the United States? Yes No If Yes, Explain

Have you ever been sanctioned, cited, reported, or excluded from participation in medicare, medicaid, or any other healthcare related law or regulation? Yes No If Yes, Explain

EDUCATION

High School

Course of Study

Degree

Graduate? Yes No

Completed:

College

Course of Study

Degree

Graduate? Yes No

Completed:

College

Course of Study

Degree

Graduate? Yes No

Completed:

Other Business College or Special Courses (include Special Military Training, Post Graduate and Nursing)

SKILLS

Area(s) of specialization or major interest

List office skills including computer/software experience

List health care, business, or industrial equipment operated

Word processing (Approx. WPM)

Briefly describe duties and skills acquired through military or volunteer service (include dates)

PROFESSIONAL LICENSES

License Status:

License or registration ever suspended, revoked or on probation? Yes No If Yes, explain:

Type

Number

State

Date

License Status:

License or registration ever suspended, revoked or on probation? Yes No If Yes, explain:

Type

Number

State

Date

PROFESSIONAL CERTIFICATIONS

Certification Status:

Type

Number

State

Date

Certification Status:

Type

Number

State

Date

Provide information regarding previous employment beginning with most recent employer.

WORK HISTORY

Job Title

From

Salary

Employer

Phone Number

Address

Supervisor

Duties

Reason for leaving

May we contact your current employer ? Yes No

Job Title

From

Salary

Employer

Phone Number

Address

Supervisor

Duties

Reason for leaving

Job Title

From

Salary

Employer

Phone Number

Address

Supervisor

Duties

Reason for leaving

Job Title

From

Salary

Employer

Phone Number

Address

Supervisor

Duties

Reason for leaving

Please identify any gaps in employment longer than 3 months

List at least 3 professional/work/school references who are not relatives or personal acquaintances.

REFERENCES

Name

Relationship

Title

Company

Address

Phone

Name

Relationship

Title

Company

Address

Phone

Name

Relationship

Title

Company

Address

Phone

Résumés must be: Word (.doc, .docx, .rtf), Works (.wks), Text (.txt) or PDF (.pdf).

RÉSUMÉ

Upload your résumé: