Application For Employment

Application For Employment
Confidential
This institution does not discriminate in hiring or employment on the basis of race, color. religious creed, national origin, sex or ancestry, or on age or physical or the basis of being used for such discrimination. This mental handicap unrelated to the ability to perform the work required. No question on this application is intended to secure information to the application will be given every consideration, however, its receipt does not imply that the applicant will be employed.
Personal Information
Date of Application*

MonthDayYear
Date
Date Available*

MonthDayYear
Date
Name*

First NameLast Name
Social Security Number*
Present Address (Street, City, State, Zipcode)*
Phone Number*
Email*
example@example.com
Permanent Address if Different than Present Address (Street, City, State, Zipcode)
Phone Number If Different than Present Phone Number)
Are you a citizen of the U.S.A.?*

YesNo
If no, type of Visa
lmmig. No.

Employment Desired

Employment Choice

	Type of Work Desired	Shift	Salary
First Choice
Second Choice
Third Choice

Will You Accept Employment of:*

Full Time?Part Time?
Are You Employed Now?*

YesNo
May We Contact Your Present Employer?*

YesNo
How Did You Learn Of This Opening*
Are You 18 Yrs or Older?*

YesNo

Education
Highest Grade Completed

Education Information*

	Name of School	Location (City, State)	Courses Taken	Date Completed	Diploma. Degree or Certificate Received
High School
College
Vocat,onal or Business
Professional Education
Laboratory or X-Ray Training

Extracurricular Activities While in School
Member of Professional Organizations
Honors Received, Volunteer or Community Service or Other Qualifications You Have Which You Feel Are Related to the Position for Which You Are Applying:
Have You Ever Been in the U.S. Armed Forces*
If yes, what is your present Selective Service Classification?
Are You Presently a Member of Reserves or National Guard?*
If so, When is your Enlistment Up?

Professional Licenses and/or Certifications*

	Type	Organization or State Issued	Date Issued	Number	Verification
1
2
3

Employment Record

List last or present position first
Previous/Current Employment
Employer's Name*
Employer's Address*
Supervisor's Name*
Phone Number*
Date Employed: From Date* To Date*
Salary Range: Starting Number* Ending Number*
Position & Duties*
Reasons for Leaving*
Previous Employment
Employer's Name
Employer's Address
Supervisor's Name
Phone Number
Date Employed: From Date To Date
Salary Range: Starting Number Ending Number
Position & Duties
Reasons for Leaving
Previous Employment
Employer's Name
Employer's Address
Supervisor's Name
Phone Number
Date Employed: From Date To Date
Salary Range: Starting Number Ending Number
Position & Duties
Reasons for Leaving
Previous Employment
Employer's Name
Employer's Address
Supervisor's Name
Phone Number
Date Employed: From Date To Date
Salary Range: Starting Number Ending Number
Position & Duties
Reasons for Leaving
Please explain all periods of unemployment.*
If your former employment references, education or military service are under name other than indicated on front of application. please indicate below.
Have you ever been convicted of a crime? If so, for what, when and where blank
Use this space to give us further information which will assist us in placing you, including at lease two personal references not related to you, whom you have known at least one year.*
Do you consider yourself to be able to perform all of the duties required by the job(s) for which you are making application without endangering yourself, other employees or patients?*
If no, please explain:

Employment Record Authorization
I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in ion. I such investigation and release from all liability or responsibility all persons, companies or corporations supplying such informat con· sent to take the preemployment physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate.

I understand that I will be required to follow the personnel policies and rules of the institution and that infractions of said rules may lead to dismissal. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

I further understand that this institution follows the "fair employment practice code" and there is no discrimination in the hiring of in· individuals based on sex, race, religion, age, or physical or mental handicap unrelated to the ability to perform the work required.

understand that if I am employed it will be on a probationary or trial basis for a period of 90 days. Upon my termination I authorize the I release of reference information on my work.
Date*

MonthDayYear
Date
Candidate Signature*

Clear

Pre-Employment Authorization Form
Note:
I understand the information requested on this form is for the sole purpose of conducting a pre-employment search and should be completed only by a candidate who has been offered (or is being considered for) a position with the company. I hereby authorize, without reservation, the performance of this pre-employment search about me at any time after receipt of this authorization and, if I am hired, throughout my employment. In giving this consent, I understand that a consumer report, court records, driving records, current and prior employment, personal references, education records, professional license records, social security records, or worker's compensation records may be requested and a search conducted to determine my suitability for employment. (Workers' compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or other applicable state laws). I further understand if employment is denied in whole or in part because of information obtained by my employer or prospective employer from a consumer reporting agency, I have the right to make a written request within a reasonable time to receive information about the scope and nature of the search. I understand the information below regarding sex and date of birth is requested for the sole purpose of gathering information accurately, and will not be used to discriminate against me in violation of the law. A facsimile or photographic copy of this authorization shall be as valid as the original. I also authorize all of my former employers (including personal and business references or self-employment to provide any information they have regarding me, whether or not it is in their records.
Candidate Signature*

Clear
Date*

MonthDayYear
Date
Name*

First NameLast Name
Maiden Name
Social Security Number*
Date of Birth*

MonthDayYear
Date
Sex*

MF
Current Address*

Street

County

CityState

Zip
County*
Yrs. in Residence*
Phone Number*

Area CodePhone Number
Previous Address

Street

Street Address Line 2

CityState

Zip
County
Yrs. in Residence
Phone Number

Area CodePhone Number
Driver's License
Driver's License Number*
State of lssue*
Date Issued*

MonthDayYear
Date
Please Print Your Name Exactly As It Appears On Your Driver's License*
Please Check if any apply to you.

NoneStatewide CriminalCounty CriminalTN Sex OffenderNational Sex Offender
Should be Empty:

	Time From	Time To
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Application For Employment

Confidential

Personal Information

Employment Desired

Education

Employment Record

Previous/Current Employment

Previous Employment

Previous Employment

Previous Employment

Employment Record Authorization

Availability Record

Pre-Employment Authorization Form

Note:

Driver's License