Equal Opportunity Employer M/F/V/D 1
Application for Employment
The Facility is an Equal Opportunity Employer. All employment decisions are made without regard to unlawful considerations of race, sex, sexual orientation, gender identity, religion, national origin, age, disability, genetic information, or any other legally protected status. Reasonable accommodations are available to qualified disabled individuals, upon request.
Personal Information
Date Name
Last First Middle
Address
Street City State Zip
Cell Phone: ( ) - Home: ( ) - Email:
Are you at least 18 years of age? Yes No If no, can you furnish a valid work permit? Yes No Personal Information
Position applied for:
Type of employment desired: Full-Time Part-Time Temporary On Call Are there any hours, shifts, or days you cannot or will not work?
Please indicate specific days and/or hours
Are you willing to work overtime as required? Yes No
Have you ever been employed with the Facility in the past? Yes No Are you related to anyone employed at this Facility? Yes No
If so, whom?
If offered employment with the Facility, will you be able to provide documentation that you are a citizen, national, lawful permanent resident or alien authorized to work in the United States? Yes No (As a condition of employment, successful candidates must provide written documentation to prove either citizenship or proper authorization to work in the United States. Specific instructions will be provided prior to your first day of employment regarding legally required documentation.)
Have you ever been convicted of a felony? Yes No (Do not respond concerning the following: arrests or detentions that did not result in conviction; referrals to, and participation in, any pretrial or post-trial diversion programs;
marijuana-related convictions more than two years old; convictions for which the record has been judicially ordered sealed, expunged, or statutorily eradicated; and misdemeanor convictions for which probation has been successfully completed or otherwise discharged and the case has been judicially dismissed.)
If yes, what was (were) the offense(s)?
Date(s) and place(s) of conviction:
A CONVICTION RECORD WILL NOT NECESSARILY BE A BAR TO EMPLOYMENT. Factors such as age at the time of the offense, type of offense and relevance to the job for which you are applying, seriousness and nature of the offense, and rehabilitation will be taken into account.
Licensure/Certification
Do you currently hold a valid professional license or certification? Yes No
If yes, note type(s): Registered Nurse LVN CNA PT ST OT
State: AZ CA UT Number: Expiration Date:
Education, Training and Experience
School Name, City, State, Country How many years
completed (select box) Major Diploma/Degree
High School 1 2 3 4
Diploma Degree
College/University 1 2 3 4 Degree
College/University 1 2 3 4 Degree
Graduate School, Technical Trade
School, other 1 2 3 4
Certificate Diploma Degree
Equal Opportunity Employer M/F/V/D 2
Employment History
List present and past employment, including military experience, starting with most recent employer. Account for all periods of unemployment. You must complete this section even if submitting a resume.
Most Recent Employer Address Telephone
Name of Supervisor Positions Held Reasons for Leaving
Date Started Date Left Ending Salary: $/per Starting Salary: $/per
Previous Employer Address Telephone Name of Supervisor Positions Held Reasons for Leaving
Date Started Date Left Ending Salary: $/per Starting Salary: $/per
Previous Employer Address Telephone Name of Supervisor Positions Held Reasons for Leaving
Date Started Date Left Ending Salary: $/per Starting Salary: $/per
References
List three persons not related to you who have knowledge of your work performance within the past three years.
Name Telephone Number Occupation # of Years Acquainted
1.
2.
3.
Applicant’s Certification and Agreement
I understand and agree that nothing contained in this application packet or in the hiring process is intended to create an employment contract. I understand that no representation, whether oral or written, by any representative or agent of the Facility, at any time, can constitute an implied or express contract of employment. If I am offered and accept employment, I agree to abide by the Facilities policies and procedures and employee handbook. IF HIRED, I UNDERSTAND AND AGREE THAT MY EMPLOYMENT WILL BE AT-WILL AND MAY BE TERMINATED AT THE OPTION OF EITHER THE FACILITY OR MYSELF, AT ANY TIME, WITH OR WITHOUT CAUSE OR ADVANCE NOTICE. In connection with this at-will policy, I understand that the Facility reserves the right to alter my position and to impose any form of discipline it determines is appropriate, at any time, at its sole discretion. I further understand that the at will employment relationship cannot be altered unless it is done specifically, in writing, and signed by the President of the Company.
I understand and agree that I must meet all the physical standards established by the Facility to perform the essential functions of any job for which I am offered employment. I understand that if offered employment I am required to complete a Post-offer, Pre-employment Health Questionnaire. I also understand that during employment I might from time to time be subjected to physical examinations and/or physical ability tests to demonstrate that I can perform the essential functions of my job. The Facility reserves the right to conduct searches on Facility property or of the Facility’s property, vehicles and/or equipment at any time. I further understand that if I refuse to submit to a Facility search I may be terminated.
By signing below, I hereby certify that all of the foregoing information I have supplied in this application is correct and complete. I understand that any falsification of information will constitute grounds for immediate dismissal upon discovery thereof. I give the Facility permission to contact any or all of my previous employers and references for full information and hereby release it from any and all liability for doing so:
Applicant’s Signature Date
Print Full Legal Name Date
Equal Employment Opportunity Data Page 1 of 2
Equal Employment Opportunity Data
SECTION A: To Be Completed by Applicant
Completion of the following information is voluntary, and will assist us in proper placement and reasonable accommodation. If you wish to be identified as qualifying for such placement or accommodation, please check where applicable.
Name:
Gender: Male Female
Race/Ethnicity: (Please choose only one. For detail descriptions, see reverse.) American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander Black or African American
White
Hispanic or Latino Two or more races
Government contractors must take affirmative action to employ and advance certain qualified individuals subject to the Rehabilitation Act of 1973 and the Vietnam Era Veterans
Readjustment Act of 1974. Completion of the following information is voluntary, and will assist us in proper placement and reasonable accommodation. If you wish to be identified as
qualifying for such placement or accommodation, please check where applicable.
Vietnam Era Veteran Disabled Veteran
Individual with a Disability
SECTION B: To Be Completed by Employer
(Please choose only one. For detailed descriptions, see reverse.)
EE0-1 Category:
1a. Officials and managers-Exec & Senior Level 1b. Officials and managers-First/Mid=Level
2. Professionals 6. Crafts
3. Technicians 7. Operatives
4. Sales 8. Laborers
5. Office and clerical 9. Service workers Employer Information completed by:
Name (must be legible) Date
Equal Employment Opportunity Data Page 2 of 2
