LVHC Employment Application

Notice to All Applicants: Screening tests for alcohol and illegal drug use may be required before hiring and during your employment here.

Date:

Date

Last Name

First Name

Middle

Work Phone:

Home Phone:

Cell Phone:

Email:

example@example.com

Street Address

City

State

ZIP

Permanent Address (If Different):

Street

City

State

ZIP

Any Other Names Used:

Preferred Method of Contact:

Position Applying For:

How did you hear about this position?

Type of Work Desired (Select All That Apply):

Regular full-time work

Regular full-time workRegular part-time workTemporary Work (e.g., summer, holidays)

Temporary Work Start:

Date

Temporary Work End:

Date

What days and times are you available?

Are you available to work overtime, if necessary?

YesNo

If hired, on what day can you start work?

Date

Have you ever applied to work for Long Valley Health Center before?

YesNo

If yes, when?

Date

Do you have any friends or relatives working for Long Valley Health Center?

YesNo

If yes, state name(s) and relationship(s)

If hired, would you have a reliable means of transportation?

YesNo

Are you at least 18 years old? If under 18, hiring is subject to verification that you are of minimum legal age.

YesNo

If hired, can you present evidence of your U.S. citizenship of proof of your legal right to live and work in the U.S.?

YesNo

Are you able to perform the essential functions of the job for which you are applying? We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.

YesNo

If no, describe the functions that cannot be performed:

Are you able to perform all other duties of the job for which you are applying? (Hire may be subject to skill and agility tests and passing a medical examination.)

YesNo

If no, describe the functions that cannot be performed:

Are you currently employed?

YesNo

If you are currently employed, may we contact your employer?

YesNo

Why are you applying for work at Long Valley Health Center?

Education, Training, and Experience

High School Name and Address

Years Completed

Did You Graduate?

Degree or Diploma

College/University School Name and Address

Did You Graduate?

Vocational/Business School Name and Address

Did You Graduate?

Health Care School Name and Address

Did You Graduate?

Many of our clients do not speak English. If you speak any other languages, which one(s)?

Do you have any other experience, training, qualifications or skills which you feel make you especially suited for work at Long Valley Health Center? If so, please explain:

Answer the following questions if you are applying for a professional position. Otherwise, continue on the next page.

Are you licensed/certified for the job for which you’re applying?

YesNo

Name of License/Certification:

Issuing State:

License/Certification Number:

Has your license or certification ever been revoked or suspended?

YesNo

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

List all present and past employment from the last 10 years starting with your most recent employer. Account for all unemployment periods. Complete this section even if attaching a resume.

Employer:

Address:

State

Zip code

Type of Business:

Phone:

Supervisor’s Name:

Position and Duties:

Start Date:

Date

End Date:

Date

Reason for Leaving:

Employer:

Address:

State

Zip code

Type of Business:

Phone:

Supervisor’s Name:

Position and Duties:

Start Date:

Date

End Date:

Date

Reason for Leaving:

Employer:

Address:

State

Zip code

Type of Business:

Phone:

Supervisor’s Name:

Position and Duties:

Start Date:

Date

End Date:

Date

Reason for Leaving:

Employer:

Address:

State:

Zip code

Type of Business:

Phone:

Supervisor’s Name:

Position and Duties:

Start Date:

Date

End Date:

Date

Reason for Leaving:

Attach additional pages if necessary.

Other Work Experience

Military Service? If so, which branch?

Describe any special skills or abilities you obtained as the result of service in the military.

References

List three persons not related to you who have knowledge of your work performance within the last three years.

Name:

Phone:

Email

Address

Street Address Line 2

City

State

Occupation:

Years Acquainted:

Name:

Phone:

Email

Address

Street Address Line 2

City

State

ZIP

Occupation:

Years Acquainted:

Name:

Phone:

Email

Address

Street Address Line 2

City

State ZIP

Occupation:

Years Acquainted:

Please read carefully, initial each paragraph, and sign below:

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 of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

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 any 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 from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I hereby agree to submit to binding arbitration all disputes and claims arising out of the submission of this application. I further agree, in the event that I am hired by the company, that all disputes that cannot be resolved by informal internal resolution which might arise out of my employment with the company, whether during or after that employment, will be submitted to binding arbitration. I agree that such arbitration shall be conducted under the rules of the American Arbitration Association. This application contains the entire agreement between the parties with regard to dispute resolution and, there are no other agreements as to dispute resolution, either oral or written.

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 contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s designated representative.

I understand that I will be required to pass a drug test before a final offer of employment is made. By signing my name below, I consent to this procedure.

Signature

Date

Employment Application

Employment Application

Employment Application

Employment Application

Employer 1

Employer 2

Employment Application

Employer 3

Employer 4

Employment Application

Reference 1

Reference 2

Employment Application

Reference 3

Employment Application