Application @ COD Health Care

1
Full Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Since you are under 18, can you produce the necessary work certificate at the time of employment?* This field is required.
Yes
No
4
E-mail* This field is required.
5
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
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Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
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Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Phone Number* This field is required.
Area Code
Phone Number
7
Which role are you applying for?* This field is required.
Please Select
DSP I (less than 2 years)
DSP II (more than 2 years verifiable experience)
DSM
Scheduler
RN
Administrative Assistant
8
Type of employment desired (check all that apply)* This field is required.
Full-Time
Part-Time
Temporary
Summer only
9
Are you willing to work overtime?* This field is required.
Yes
No
10
Do you have reliable transportation?* This field is required.
Yes
No
11
Do you have a valid driver's license?* This field is required.
Yes
No
12
Driver's License* This field is required.
Driver's License Number
OH
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
13
Please upload a picture of your Driver's License* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
14
If hired, can you provide proof you are eligible to work in the U. S.?* This field is required.
Yes
No
15
Is there any time that you cannot work?
16
Which date can you begin working?
Date
Month
Day
Year
17
Most Recent Employer* This field is required.
18
City, State, CountryOptional
19
Employer phoneOptional
Area Code
Phone Number
20
Position HeldOptional
21
Supervisor nameOptional
First Name
Last Name
22
Reason for leaving* This field is required.
23
Most recent completed education level* This field is required.
Please Select
Please Select
High School/GED
Associate's Degree
Bachelor's Degree
Master's Degree
Doctoral Degree
Other Education/Certifications
24
Please specify - Other Education/Certifications* This field is required.
25
Name of Institution* This field is required.
26
City, State, CountryOptional
27
Date completed* This field is required.
Date
Month
Day
Year
28
Have you ever been convicted of a crime, excluding minor traffic violations?* This field is required.
Yes
No
29
If yes, please explain* This field is required.
30
Are you willing to do a background check?* This field is required.
Yes
No
31
How did you hear about us?
Please Select
Please Select
Company Website
Job Board (e.g., Indeed, LinkedIn)
Social Media (e.g., Facebook, Twitter)
Employee Referral
Career Fair
University/College
Recruitment Agency
Other (Please specify)
32
Provide the employee's name if possible
33
Specify the event
34
Specify the name
35
Please specify
36
What is your race/ethnicity?
Please Select
White
Black or African American
Hispanic or Latino
Asian
Native American or Alaska Native
Native Hawaiian or Other Pacific Islander
Two or More Races
Prefer not to say
37
I certify that the information provided on this application is true and complete to the best of my knowledge. I understand that any false statements, omissions, or misrepresentations may result in disqualification from employment or termination if already employed.

I understand that this application does not constitute a contract of employment and that, if hired, my employment with COD Health Care is "at-will," meaning that either the company or I may terminate the employment relationship at any time, with or without cause or notice.

By signing below, I acknowledge that I have read, understood, and agree to the terms and conditions outlined above.
38
Today's Date* This field is required.
Date
Month
Day
Year
39
Name* This field is required.
First Name
Last Name
40
Signature* This field is required.
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