APPLICATION FOR EMPLOYMENT

PRE-EMPLOYMENT SCREENING IS REQUIRED

Applications are considered for all positions without regard to race, color, religion, sex, national origin, age,
maritime/veteran status, or disability.

PERSONAL INFORMATION

FIRST NAME: MIDDLE INITIAL:

LAST NAME:

ADDRESS:

CITY: STATE: ZIP:

SOCIAL SECURITY NUMBER:

E-MAIL ADDRESS:

DAYTIME TELEPHONE:

EVENING TELEPHONE:

CELL PHONE:

EDUCATION

HIGH SCHOOL:

ADDRESS:

CITY: STATE: ZIP:

COUNTRY: PROVINCE:

MAJOR:

DID YOU GRADUATE? YES NO YEARS COMPLETED: DEGREE TYPE:

 APPLICATION FOR EMPLOYMENT (Page 2)
COLLEGE / UNIVERSITY:

ADDRESS:

CITY: STATE: ZIP:

COUNTRY: PROVINCE:

MAJOR:

DID YOU GRADUATE? YES NO YEARS COMPLETED: DEGREE TYPE:

GRADUATE / PROFESSIONAL:

ADDRESS:

CITY: STATE: ZIP:

COUNTRY: PROVINCE:

MAJOR:

DID YOU GRADUATE? YES NO YEARS COMPLETED: DEGREE TYPE:

OTHER EDUCATION:

ADDRESS:

CITY: STATE: ZIP:

COUNTRY: PROVINCE:

MAJOR:

DID YOU GRADUATE? YES NO YEARS COMPLETED: DEGREE TYPE:

 APPLICATION FOR EMPLOYMENT (Page 3)
HONORS & AWARDS:

SKILLS / EXPERIENCE:
Describe Specialized Training, Apprenticeship, Skills with number of years experience. Describe any extra-curricular
activities.

ADDITIONAL INFORMATION:
Please provide any additional information you would like considered with your application, particularly anything you
believe would be helpful to us in considering you for the position.

LANGUAGE PROFICIENCY:
The primary requirement of most positions is English. Please indicate any additional languages you speak, read, or
write.

LICENSES
Professional Licensure (please list Dates of Issue and Expiration in DD/MM/YY format):

License/Ceritifcation State License Number Date Issued Date Expires Temporary?

License(s) applied for (state/country)

License: State: Country:

License: State: Country:
License: State: Country:
 APPLICATION FOR EMPLOYMENT (Page 4)
WORK HISTORY
Starting with your PRESENT or LAST employer, please give your employment history, military, and other
relevant work/volunteer experience within the last 10 years. Periods of unemployment must be explained in
the Summary section.

Employer:
Street Address:
City:
State:
Zip:
Telephone Number:
Job Title:
Employed From: To:
Starting salary:
Ending salary:
Supervisor:
May we contact this employer for a reference? Yes No
Principal Work Performed:
Reasong for leaving:

Employer:
Street Address:
City:
State:
Zip:
Telephone Number:
Job Title:
Employed From: To:
Starting salary:
Ending salary:
Supervisor:
May we contact this employer for a reference? Yes No
Principal Work Performed:
Reasong for leaving:
 APPLICATION FOR EMPLOYMENT (Page 5)

Employer:
Street Address:
City:
State:
Zip:
Telephone Number:
Job Title:
Employed From: To:
Starting salary:
Ending salary:
Supervisor:
May we contact this employer for a reference? Yes No
Principal Work Performed:
Reasong for leaving:

Employer:
Street Address:
City:
State:
Zip:
Telephone Number:
Job Title:
Employed From: To:
Starting salary:
Ending salary:
Supervisor:
May we contact this employer for a reference? Yes No
Principal Work Performed:
Reasong for leaving:
 APPLICATION FOR EMPLOYMENT (Page 6)
PERSONAL REFERENCES
Please give three (3) references (DO NOT list relatives or previous employers).

Name: Phone Number: Address: Relationship:

ADDITIONAL INFORMATION

Minimum Salary Requirement:

On what date are you available for work?:

How did you find out about this position?:

If you were referred by a current employee,

please enter their name and department:

Do you have any relatives currently employed here? YES NO

If “yes,” please list their name(s) and department(s):

What job status would you accept? Full-Time Per Diem Weekend
Part-Time Temporary
What shift would you accept? 1st 2nd 3rd
7am-7pm 7pm-7am

PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS:

Can you furnish a work permit if you are under 18? YES NO

Are you prevented lawfully from becoming employed in this country because of
Visa or immigration status? YES NO

Can you travel if a job requires it? YES NO

Have you ever been employed here or at another facility of our organization? YES NO
If “yes,” please give the dates of your employment:

From: To:

Are you on a lay-off and subject to recall? YES NO

Have you filed an application here before? YES NO

If “yes,” please give the date of your most recent application:

Have you ever been convicted of a crime? YES NO

If “yes,” please explain:
 APPLICATION FOR EMPLOYMENT (Page 7)
Are you able to perform all the functions of the job for which you are applying, with or without
accommodations?

YES NO

If you indicated you can perform all the functions with an accommodation, please explain how you would
perform the tasks and with what accommodations:

(END)
 Applicant’s Certification & Agreement
(Please read carefully & sign upon completion)

In consideration of being employed, I understand and agree that:

1. If I misrepresent or deliberately leave out a fact in my application, I may be refused employment

or, if employed, I may be terminated.
2. The employer has my authorization to thoroughly investigate my work and personal and credit
history and I hereby consent to take any test, whenever the employer deems it necessary in any
employer investigation. I will hold no person, corporation, or organization liable for giving or
receiving information in such investigation.
3. If employed, I may terminate my employment at any time without notice or cause, and the
employer may terminate or modify the employment relationship at any time without notice or
cause. In consideration of my employment, I agree to conform to the rules and regulations of
the employer, and I understand that no department head or representative of the employer,
other than the President of the Company, has any authority to enter into any agreement, oral
or written, for employment for any specified period of time or to make any agreement or
assurances to the contrary of this policy.
4. Any doctor, hospital, or testing laboratory has my consent to conduct medical or drug tests on
me, and I hereby give my consent to having all information released for the employer to
determine my abilities to perform job duties now or in the future. I also give my consent to
physical searches of myself and my briefcase, lunch box, car, locker, or any packages or purse
I have while on the employer’s premises whether or not I have a lock on such items.
5. The needs of the employer may make the following conditions mandatory: overtime, shift work,
rotating work schedule, or a work schedule other than Monday through Friday. I accept these
conditions of employment.
6. The employer is an equal-opportunity employer. The employer does not discriminate in
employment and no question on my employment application is used for the purpose of
limiting or excluding any applicant’s consideration for employment on a basis prohibited by
local, state, or federal law.
7. If employed, I understand that my employment is for no definite period of time, and if terminated,
the employer is liable only for the wages or salary earned as of the date of termination.
8. I understand that the employer requires all staff to report sanction, convictions, suspensions,
censures, or revocation (“sanction”) action taken against them by federal, state, local, or other
professional entities. These sanctions may include but are not limited to infractions against
professional licensure, criminal history of convictions, history of child abuse, managed care
organizations, etc.
9. This application is current and active only for six months. At the conclusion of this time, if I have
not had any contact from the employer and still wish to be considered for employment, it will be
necessary for me to fill out a new application.
10. If employed, I understand that I must abide by the Company’s established Service Excellence
standards and realize that Service Excellence is a priority of the Company.

Should you be called for an interview, you will be asked to read & sign this
Certification & Agreement
I have read and agree to the previous terms, and hereby certify that the facts I
have provided in my employment application are true and complete.
PRINTED NAME:

SIGNATURE:

DATE: