Employment Form

Personal Information

Please provide any applicable information:

Professional License #

State & Expiration Date

Malpractice Insurance #

Expiration Date

CPR

Expiration Date

Valid Driver's License

Yes

Auto Insurance Carrier

Have you ever applied to or worked for this company before?

Yes

If yes, when and which position?

Do you have any friends or relatives working for this company?

Yes

If yes, please state names(s) and relationships

Referred by

Date you can start work if hired

If hired, would you have a reliable means of transportation to and from work?

Yes

Are you at least 18 years old?

Yes

If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?

Yes

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation

Yes

If no, describe the function that cannot be performed.

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)

Have you ever been convicted of a criminal offense (felony or serious misdemeanor)?

Yes

(Misdemeanor convictions for amrijuana-related offenses taht are more than two years old need to be listed.)

If yes, state nature of the crime(s), when and where convicted, and disposition of the case.

(Note: No applicatn will be denied employment solely on the grounds of conviction of a crime offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Have you ever been terminated from a job for abusive conduct to any other person including but note limited to assault, battery, etc?

Yes

High School

School Name

State

# of years completed

Did you Graduate?

Yes

Degree or Diploma

College/University

School Name

State

# of years completed

Did you Graduate?

Yes

Degree or Diploma

Vocational

School Name

State

# of years completed

Did you Graduate?

Yes

Degree or Diploma

Health Care Training

School Name

State

# of years completed

Did you Graduate?

Yes

Degree or Diploma

Do you have a professional license?

Yes

If so, when does it expire

Do you have malpractice insurance?

Yes

If so, when does it expire

Are you certified in CPR?

Yes

If so, when does it expire

Do you have auto insurance coverage?

Yes

If so, when does it expire

Employment History

Please list below the past fie years of employment starting with your most recent employer. You must complete this section even if attaching resume.

Name of Employer

Type of Business

Phone Number

Address

City

State

Zip Code

Supervisor's Name & Job Title

Work From and To

Pay Start and End

Your Position and Duties

May we contact this employer for reference?

Yes

Reason for Leaving

Name of Employer

Type of Business

Phone Number

Address

City

State

Zip Code

Supervisor's Name & Job Title

Work From and To

Pay Start and End

Your Position and Duties

May we contact this employer for reference?

Yes

Reason for Leaving

Name of Employer

Type of Business

Phone Number

Address

City

State

Zip Code

Supervisor's Name & Job Title

Work From and To

Pay Start and End

Your Position and Duties

May we contact this employer for reference?

Yes

Reason for Leaving

Name of Employer

Type of Business

Phone Number

Address

City

State

Zip Code

Supervisor's Name & Job Title

Work From and To

Pay Start and End

Your Position and Duties

May we contact this employer for reference?

Yes

Reason for Leaving

Name of Employer

Type of Business

Phone Number

Address

City

State

Zip Code

Supervisor's Name & Job Title

Work From and To

Pay Start and End

Your Position and Duties

May we contact this employer for reference?

Yes

Reason for Leaving

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, the undersign applican, have personally completed this application. I understand that any omission or misstatement of 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 before discovery.

I hereby authorize the company 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 company 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 Company, 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 any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. 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 or the Company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Company’s designated representative.

Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien or outstanding judgment) be conducted by internal personnel employed by the Company, I am entitled to copies of any such public records obtained by the Company unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box below.