GENERAL INFORMATION
Name
Street Address
City
State
Email Address
Day Phone Number
Evening Phone Number
Social Security Number
EMPLOYMENT DESIRED
Position applying for
Are you applying for
Please check the appropriate box
What days and hours are you available?
If you are applying for temporary work, during what period of time will you be available?
From:
Are you available on weekends?
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YES
NO
Would you be available to work overtime, if necessary?
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YES
NO
If hired, on date can you start work?
Salary Desired
Are you currently employed?
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YES
NO
May we contact your employer?
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YES
NO
Are you legally able to work in this country?
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YES
NO
Proof of citizenship or immigration status will be required upon employment.
Who referred you to this organization?
Employment Agency
Newspaper Advertising
Friend
State Employment Office
College Placement Service
Walk-in
Other
For Other, please list:
EDUCATION, TRAINING AND EXPERIENCE
Select One
Many of our patients/clients do not speak English. Do you speak any foreign language?
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Yes
No
Which Language
Do you have any other experience, training, qualifications or skills which you feel make you especially suited for work at our organization? If so, please explain.
Answer the following questions if you are applying for a professional position.
Are you licensed/certified for the job applied for?
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Yes
No
Name of license/certification:
Issuing State
License/Certification Number
Has your license/certification ever been revoked or suspended?
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Yes
No
If yes, state reason(s), date of revocation and date of reinstatement
FORMER EMPLOYERS
Name of Employer
Street Address
City
State
Type of Business
Supervisor's Name
Your Position and Duties
Dates of Employment
Weekly Pay
Starting:
Reason for Leaving
Name of Employer
Street Address
City
State
Type of Business
Supervisor's Name
Your Position and Duties
Dates of Employment
Weekly Pay
Starting:
Reason for Leaving
Name of Employer
Street Address
City
State
Type of Business
Supervisor's Name
Your Position and Duties
Dates of Employment
Weekly Pay
Starting:
Reason for Leaving
REFERENCES
Below give the names of three persons you are not related to, whom you have known at least one year.
SERVICE RECORD
Branch of Service
Discharge Date
CRIMINAL RECORD
Have you been convicted of a felony within the last 5 years?
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Yes
No
If yes, please explain. (This will not necessarily exclude you from consideration):
PLEASE READ CAREFULLY, CHECK EACH PARAGRAPH AND SUBMIT BELOW
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application. I understand that any omission or misstatement for material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed upon discovery.
I hereby authorize the organization to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and further, authorize the references I have listed to disclose to the organization any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the organization, my former employers and all other persons, corporations, partnerships, and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
I understand that nothing contained in the application, or conveyed during the interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the organization. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself of the organization, and that no promises or representations contrary to the foregoing are binding on the organization unless made in writing and signed by me and the organization's designated representative.
