Online Employment Application

Date

Month

Day

Year

First name

Last name

Email

Phone:

Social Security #

Multi-line address

Country/Region

Address

City

Zip / Postal code

Position Applying For:

Regular Full-Time Work:

Yes

No

Regular Part-Time Work:

Yes

No

Temporary Work (Holidays, Summer, Etc.):

Yes

No

What days/hours are you available to work?

If applying for temporary work, during what period of time are you available?

Are you available to work weekends?

Yes

No

Are you available to work overtime, if necessary?

Yes

No

If hired, on what date can you start work?

Salary Desired:

Are you currently employed?

Yes

No

May we contact your current employer?

Yes

No

Not Applicable

Are you legally able to work in this country? (Proof of citizenship or immigration status will be required upon employment.)

Yes

No

Who referred you to this company?

High School Attended:

Did you graduate?

Yes

No

College/University Attended?

Did you graduate?

Yes

No

Not Applicable

Vocational/Business?

Did you graduate?

Yes

No

Not Applicable

Healthcare Training:

Did you complete?

Yes

No

Not Applicable

Many of our patients/clients do not speak English. Do you speak, write or understand any foreign languages?

Yes

No

If yes, what languages?

Do you have any other experience, training, qualifications or skills which you believe make you especially suited for work at this company? 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?

Yes

No

Name of license/certification:

Date of Certification:

Expires:

Issuing State:

License/Certification #:

Has your license/certification ever been revoked or suspended?

Yes

No

If yes, state reason(s), date of revocation or suspension and date of reinstatement:

Attach additional employment and references with professional resumé, if applicable:

Name of Previous Employer 1:

Previous Employer Address:

Type of Business:

Previous Employer's Phone:

Supervisor's Name:

Your Position & Duties:

Date of Employment (From/To):

Weekly Pay (Starting/Ending):

Reason For Leaving:

Name of Previous Employer 2:

Previous Employer Address:

Type of Business:

Previous Employer's Phone

Supervisor's Name:

Your Position & Duties:

Date of Employment (From/To):

Weekly Pay (Starting/Ending):

Reason For Leaving:

NAME, ADDRESS, BUSINESS & YEARS ACQUANITED of 3 persons you are not related to, whom you have known at least one year:

Have you served in the armed forces?

Yes

No

If yes, Branch of Service:

Rank:

Discharge Date:

Have you been convicted of a felony within the last 5 years?

Yes

No

If "yes", explain (this will not necessarily exclude you from consideration):

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 undersigned applicant, 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.

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 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.

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.

Date

Month

Day

Year

Signature

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