|
Personal Information
|
First Name:
|
Middle Name:
|
Last Name:
|
Maiden Name:
|
Social Security Number (Optional):
|
Email Address:
|
| Present Address: |
How long have you lived at your present address?
|
Telephone:
|
If under 18, please list age:
|
|
Requirements & Availability
|
Position Applying For:
|
Location:
|
Salary Desired:
|
Days/Hours Available to Work:
No PreferencePreference:
Mondays
Tuesdays
Wednesdays
Thuursdays
Fridays
SaturdaysShifts Available:
Days
Nights |
Can you work nights?
|
How many hours can you work weekly?
|
Employment Desired:
Full-TimeOnly
Part-Time Only
Full- or Part-Time |
When are you available to start work?
|
|
Education Information
|
High School Name & Location:
|
Do you have a:
High School Diploma
GED
Neither |
College Name & Location:
|
Degree Type:
Associates
Bachelors
Masters
PhD
Other |
Major:
|
College Name & Location:
|
Degree Type:
Associates
Bachelors
Masters
PhD
Other |
Major:
|
|
Background Information
|
Have you ever been convicted of a crime?
Yes
No |
| If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation. |
|
|
Driving Information
|
Do you have a driver’s license?
Yes
No |
Driver’s License Number & State of Issue:
|
What is your means of transportation to work?
|
Have you had any accidents involving a vehicle during the past three years?
Yes
No |
If yes, how many?
|
Have you had any moving violations during the past three years?
Yes
No |
If yes, how many?
|
|
Military Expereince
|
Have you ever been in the armed forces?
Yes
No |
Are you now a member of the national guard?
Yes
No |
| If you answered yes to either of the questions above, please explain (Specialty, Date Entered & Discharge Date). |
|
Work Experience
|
Please list your work experience for the past five years beginning with your most recent jobheld. If you were self-employed, give firm name. If you have held more than 3 jobs in the last 5 years, please also upload a resume at the end of this application. |
Name of Employer #1:
|
Job Title:
|
Start Date:
|
End Date:
|
Starting Salary:
|
Ending Salary:
|
Name of Last Supervisor:
|
| Complete Address of Employer: |
Supervisor’s Phone Number:
|
| List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this comapany. |
| Reason for Leaving (be specific): |
Name of Employer #2:
|
Job Title:
|
Start Date:
|
End Date:
|
Starting Salary:
|
Ending Salary:
|
Name of Last Supervisor:
|
| Complete Address of Employer: |
Supervisor’s Phone Number:
|
| List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this comapany. |
| Reason for Leaving (be specific): |
Name of Employer #3:
|
Job Title:
|
Start Date:
|
End Date:
|
Starting Salary:
|
Ending Salary:
|
Name of Last Supervisor:
|
| Complete Address of Employer: |
Supervisor’s Phone Number:
|
| List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this comapany. |
| Reason for Leaving (be specific): |
May we contact your present employer?
Yes
No |
|
References
|
|
Please list two references other than relatives or previous employers.
|
Name (Reference #1):
|
Company:
|
Position:
|
| Address: |
Telephone:
|
E-mail:
|
Name (Reference #2):
|
Company:
|
Position:
|
| Address: |
Telephone:
|
E-mail:
|
| Application Form WaiverPlease read carefully. You must check all boxes in order for your application to be considered. |
In exchange for the consideration of my job application by Healthcare Express (hereinafter called “the Company”), I agree that:
Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Healthcare Express or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President of the Company. Both the undersigned and Healthcare Express may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.
I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy.
I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.
I further understand that my employment with the Company shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party. |
By checking the boxes below you indicate:
You are the person you claim to be on the application.
All information contained in the application is true to best of your knowledge. |
Did you complete this application yourself?
Yes
No |
If no, who did?
|
Resume & Cover LetterYour resume and cover letter must be sent as either an Adobe PDF or a Microsoft Word Document. Any other format will not be opened.
|
Attach Your Resume:
|
Attach Your Cover Letter:
|
|
|
