CMS HIPAA Notice of Privacy Practices

Employment Application


THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT but merely is intended to evaluate suitability for employment. It is the policy of the company to provide equal employment to all qualified persons without discrimination on the basis of sex, race, color, religion, age, national origin, citizenship, disability, veteran status, or any other status protected under local, state or federal law. It is also the policy of the company to have the option of conducting pre-employment screening before a job offer is made. If a job offer is made, employment may be contingent upon the successful completion of a pre-employment drug screening and/or medical examination. This application will remain active for 3 years.
Referral Select Referral Method: 
Job Posting Select Posting to Apply for: 
Personal Information
Addresses
Street City State Zip Code Since (Mo/Yr) To (Mo/Yr)
Current Address
Prior Address
Prior Address:
Education
School Attended City State Diploma Degree/Cert. Area of Study
High School
GED
Undergrad School
Grad School
Other School
Employment Information
Position Applied For Date You Can Start
 (yyyy-mm-dd) 		Desired Salary: $
Do You Prefer Can you work  Weekends
 Evenings 		Available: M Tu W Th F Sa Su
Are you available for shift work?
Not Available
Please answer all of the following questions.
1. Are you at least 18 years of age and legally eligible to work for our company in the United States?
If you are under 18 years of age, can you provide required proof of your eligibility to work?
2. Have you worked for this business before?
If yes, please provide dates and locations.
3. Have you received a description of the job or been made aware of the essential functions of the job for which you are applying?
4. Do you understand the job requirements?
If no, please explain.
5. Are you on layoff and subject to recall?
6. Are you currently bound by a noncompetition, confidentiality or trade secret agreement?
If yes, please explain...
7. Have you ever been discharged or asked to resign from a job?
If yes, please explain...
8. Have you ever been convicted of or pled guilty to a felony or crime other than a minor traffic citation?
If yes, please explain...
9. Do any of your friends or relatives, other than spouse, work here?
If yes, state name and relationship...
Employment History
Are you currently employed?
May we contact your present employer?
Most Recent Employer Prior Employer Prior Employer Prior Employer
Employer
City
State
Zip Code
Phone
Position Held
From (m/yyyy)
To (m/yyyy)
Pay upon leaving
Supervisor
Duties
Reason For Leaving
Job-related Skills
Please answer the following questions if the position you are applying for requires driving a motor vehicle
1. Do you have a valid driver's license?
If yes, Driver's License Number
Date of Issue
2. Have you been convicted of or pled guilty to any traffic-related offense within the past five years?
If yes, please explain...
3. Have you had your driver's license suspended or revoked or had your driving privileges modified by a court of law?
If yes, please explain...
4. Please list all states from which you hold or held a driver's license
5. Please use this space to list any special skills you may have that relate to the position applied for
6. Please list any professional licenses, designations, certifications, etc. that may relate to the position applied for. Include date granted, name of organization, and any other relevant information.
References
Reference (1) Reference (2) Reference (3) Reference (4)
Name
Address
Telephone
Relationship
Years Acquainted
Resume (Text Version)
Copy and Paste a text version of your resume here.
Upload File
Attach a file to your application submission (Permitted File Types: doc,docx,pdf,txt - Max file size: 1045876 bytes)
Applicant Certification Agreement
1. The company and other persons or employers are released from all liability brought forth by any investigation resulting from my submission of this electronic application and the data contained here in.
2. The information in this application is true and complete to the best of my knowledge. Any falsification, misrepresentation, or omission on this application can be cause for denial or termination of employment.
3. If hired, my employment is voluntary, meaning that either party can employment at any time for any reason. Upon acceptance of employment if a position is offered, I agree to abide by all existing and future company rules and regulations. The company reserves the right to change any working agreement as deemed necessary.
4. Any employment offer is contingent open my providing proof of identity and eligibility to work the country of employ.
5. I have read and reviewed the information provided in this application and the above statements. By signing this application for employment I certify that I understand all parts of it and have answered all questions completely and fully.
6. I understand that by typing my name in the signature box below and submitting this application electronically, this becomes a legal and binding contract.
Security Code
  captcha
Type Name in Signature Box: Date: 2024-11-01 03:30:42

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