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Job Application

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Contact Information

Position applied for

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First Name

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Middle Name

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Last Name

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Street Address

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City

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State

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Zip

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Email

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Phone

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Second Phone
Best time to contact you

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Personal Information

Previous name
Have you ever gone by any previous name(s)? Yes   No

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If yes, identify all other names including maiden name:

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Eligibility
I am a U.S. Citizen (or I am an legally authorized for work in the U.S.)
 

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Are you at least 18 years old?
 

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If you answer "yes" to either of the following two questions, you will not automatically be disqualified from employment consideration, except as required by state or federal law.

Criminal Record

Have you ever been convicted of, or plead guilty to a crime (excluding misdemeanor traffic violations)?
Note: You are not required to disclose SEALED or EXPUNGED criminal records.
Yes   No

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Are you presently charged with any violation of the law?
If yes, give date, place and nature of each such event:

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If yes, explain:

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Child abuse/neglect

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

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If yes, explain:

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Are you currently excluded from participation in any federally funded healthcare program – including Medicare and Medicaid – and are you aware of any potential exclusion from a federally funded health program?

Employment Information

Type

Please check all that apply:

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Availability

Please check all that apply:

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Shift preference

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Salary desired
$

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Are You Willing to Relocate
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?
If overtime work is required periodically, does this pose a problem for you?
Are you related to another facility employee?
How did you learn about this position?
State Employment Commission Internet Agency Ad Job Listing School Current Employee Job Line Other
Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?
Describe any accommodations necessary:

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Were you referred to us?

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Do you have friends/relatives employed with us?
 
If yes, please enter their name(s), department(s), and relationship(s) below:

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Have you ever been employed by us?
 

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If yes, when:

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Date available
MM/DD/YYYY

Education & Training

Name and Address of High School

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Course of Study

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Years Completed

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Did you graduate?
   

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List diploma or degree

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Name and Address of College

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Course of Study
Years Completed
Did you graduate?
 
List diploma or degree
Name and Address of Graduate School

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Course of Study
Years Completed
Did you graduate?
 
List diploma or degree
Name and Address of Other School

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Course of Study
Years Completed
Did you graduate?
 
List diploma or degree
Business School (or special courses)
Include special military training, post graduate and nursing:

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Area(s) of specialization/interest

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Professional Licenses

Type
Number
State
Date
MM/DD/YYYY
Status
Currently licensed
Currently registered
Eligible for license
Eligible for registration
License or registration ever suspended, revoked or on probation?
Yes   No
If yes, explain:

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Type
Number
State
Date
MM/DD/YYYY
Status
Currently licensed
Currently registered
Eligible for license
Eligible for registration
License or registration ever suspended, revoked or on probation?
Yes   No
If yes, explain:

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Professional Certifications

Type
Number
State
Date
MM/DD/YYYY
Status
Currently Certified
Eligible for Certification
Type
Number
State
Date
MM/DD/YYYY
Status
Currently Certified
Eligible for Certification

Other Skills

Typing WPM

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Proficient in software

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Business machines and/or equipment you can operate
Other

Previous Experience

Provide information regarding previous employment beginning with most recent employer:

Employment Dates
- MM/DD/YYYY

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Job Title

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What was your schedule?
Full Time Part Time PRN Hours per week
Duties & Responsibilities

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Employer Name & Address

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Supervisor's Name

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Supervisor's Phone

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Salary (Hr/Mo/Yr)

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Reason for leaving

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May we contact your current employer?
Yes   No

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Employment Dates
- MM/DD/YYYY
Job Title
What was your schedule?
Full Time Part Time PRN Hours per week
Duties & Responsibilities

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Employer Name & Address

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Supervisor's Name
Supervisor's Phone
Salary (Hr/Mo/Yr)
Reason for leaving
Employment Dates
- MM/DD/YYYY
Job Title
What was your schedule?
Full Time Part Time PRN Hours per week
Duties & Responsibilities

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Employer Name & Address

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Supervisor's Name
Supervisor's Phone
Salary (Hr/Mo/Yr)
Reason for leaving
Employment Dates
- MM/DD/YYYY
Job Title
What was your schedule?
Full Time Part Time PRN Hours per week
Duties & Responsibilities

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Employer Name & Address

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Supervisor's Name
Supervisor's Phone
Salary (Hr/Mo/Yr)
Reason for leaving
Employment Dates
- MM/DD/YYYY
Job Title
What was your schedule?
Full Time Part Time PRN Hours per week
Duties & Responsibilities

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Employer Name & Address

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Supervisor's Name
Supervisor's Phone
Salary (Hr/Mo/Yr)
Reason for leaving
Gaps in employment
Please identify and explain any gaps in employment longer than three (3) months:

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Professional References

Give References other than relatives who have a good knowledge of your work.

Name, Title, Company Name, Company Address, Phone Number, Number of years known.

Reference 1

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Reference 2

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Reference 3

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Armed Services/Volunteer Information

Have you served in the U.S. Armed Services?
 

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If yes, which branch?
Have you volunteered your time or services?
 

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If yes, where?
Skills acquired
Briefly describe duties performed and skills acquired through military and/or volunteer service (include dates):

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Languages

Note: Please do not complete this section unless specifically requested to do so.

Language
Do you speak?
   
Do you read?
   
Do you write?
   
Language
Do you speak?
   
Do you read?
   
Do you write?
   

Resume

Select file

Signature

Carefully read this section prior to submitting the form.

I hereby affirm that the information provided on this application (and accompanying resume) 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 unto any agreement to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.

Date: 03/21/2019

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