Employment Application Form

Name*

First NameLast Name
Phone Number*
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How were you referred to us?*

Walk-InReferralNewspaper AdFacebookTwitterLinkedInOther (please specify)
Are you 18 years of age or older?

YesNo
Are you currently or have you ever been sanctioned by a healthcare licensing agency in this state, any other United State, or foreign jurisdiction?

YesNo
Can you provide the necessary documentation to prove that you are a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States?

YesNo
If applicable, upload here:

Cancelof
Current Employer (or most recent):
Current Job Title:
Current Job Duties:
May we contact your current employer?

YesNo
Date available for employment?

MonthDayYear
Date
Highest Education:
Highest Education:

GEDHigh SchoolCollegeMastersPHD
If graduated, what degree did you receive?
Have you ever been employed by Mission Point Healthcare Services or any of our current facilities?

YesNo
If extended a job offer, are you willing to submit to a detailed background check?

YesNo
Resume

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What position are you applying for?
What facility are you applying for?
Training and Certifications
Shift availability and preferences:
References

Please list three (3) references that are familiar with your work life.
Reference
Reference
Reference
I hereby certify that I have not been convicted and/or found guilty of resident or patient abuse, neglect or mistreatment, or of misappropriation of resident or patient property in this state or in any state, and that I am not listed in any resident or patient abuse registry in this state or in any other state. I understand that any offer of employment that is extended to me by a Mission Point Health Services location is conditional upon the verification of this information with the state patient abuse registry and that a listing in such a registry of any other state may act as an automatic withdrawal of any such offer of employment. I further understand that if I’m applying for a licensed or certified position, any offer of employment by a Mission Point location is conditional upon verification of my license or certification with the appropriate state agency. In the event that I have not yet been so licensed or certified and in the event than I am offered employment with Mission Point, I agree to undertake the required training and competency certification requirements immediately upon commencing employment.
We conduct criminal background screens and driver's license checks on anyone who is offered employment with us. These screens include felonies as well as convictions for misdemeanors and driving offenses (e.g., DUI-Driving under the influence, DWI-Driving while intoxicated, MIP-Minor in possession, etc.). We will not automatically exclude applicants with criminal records from consideration but will consider the nature of the offense, the time that has passed, and whether it is relevant to the job being sought. We do require that applicants answer truthfully. Have you ever been convicted of a felony or misdemeanor and/or have any current charges pending against you?
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