AWS Employment Application

EMPLOYMENT/CONTRACTOR APPLICATION:

To the applicant: You must fully complete this application for it to be considered. Applicants active for ninety (90) days; thereafter, you must personally renew the application to be considered for employment.

Notice: If you are applying for a position that will include involvement with adolescents and/or children you will have a criminal background check performed prior to your employment.

Equal Opportunity Employer: It is the policy of this organization to abide by all federal and state laws and regulations prohibiting employment discrimination solely on the bases of a person’s race, color, national origin, religion, age, sex, or disability.

Name

First Name Last Name

Mailing Address:

Telephone Number

Email

Birthdate

Social Security Number

Have you been convicted of a felony in the past 10 years?

Yes No

(A conviction will not automatically disqualify you for a particular job. The type and seriousness of the crime, the frequency of violations and the date of the conviction will be considered, along with your entire work and education history.)

If hired, can proof be provided of eligibility to work in the United States?

Yes No

Employment-Related Information:

Position Applying For:

Are you willing to work weekends and/or overtime if required?

Yes No

Are there any shifts or hours you cannot work?

Yes No

If "yes" when?

Have you ever applied or worked for this company before?

Yes No

If "yes" when?

Education and Training:

Highest level of education completed:

List any other education, training, special skills or certificates/licenses that you have acquired which relate to this job:

List any machines or equipment that you are qualified or experienced to operate:

EMPLOYMENT/CONTRACTOR APPLICATION:

Former Employers: (List below your last three employers starting with your present or most recent employer)

Employer:

Dates worked to and from:

Address:

Phone:

Salary start and end:

Job Title:

Supervisor:

Reason for leaving:

Employer:

Dates worked to and from:

Address:

Phone:

Salary start and end:

Job Title:

Supervisor:

Reason for leaving:

Employer:

Dates worked to and from:

Address:

Phone:

Salary start and end:

Job Title:

Supervisor:

Reason for leaving:

If employed, may we contact your employer?

Yes No

Are you presently on Lay-Off Status?

Yes No

References:

Give names, addresses and telephone numbers of three references (not relatives or former employees).

Reference 1

Reference 2

Reference 3

I acknowledge that the answers I have given are true to the best of my knowledge. I authorize criminal background investigation as well as investigation of statement and reference herein as may be necessary. I understand that false and/or misleading statements or omissions of fact may result in termination of employment or contractor status. In keeping with the DrugFree Workplace Act of 1988, successful candidates may be required to consent to an alcohol and/or drug test(s) before beginning work.

During my employment/contractor status, I agree to devote my time, attention and skill solely to the business of this work site. I will not disclose to any person any information concerning clients of this organization, current or former, or any information about the business of the corporation without appropriate consent as outlined in the Corporation Policy

Attachments:

Along with this application, we require the following items to be attached to this application.

You can add multiple files in each area. Just click on browse files again.

Resume

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All licenses and certifications associated for this position. (License candidates please include a copy of your supervision agreement.)

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NPI and taxonomy

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Oklahoma Health Care Authority Registration (either the email they send or the first screen from your provider portal)

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