EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

First Alliance Healthcare of Ohio

5900 Landerbrook Drive. Suite 301 Mayfield Hts. Ohio, 44124

Office: 216-417-8813

Web: www.firstalliancehc.com
EMPLOYMENT APPLICATION
PLEASE READ AND FOLLOW INSTRUCTIONS CAREFULLY
1. Type or Print Clearly in Black Ink

2. Resumes may be submitted with the application for supplemental information.

3. Applications should be submitted on or before the closing date, completed (including supplemental applications and transcripts where indicated), dated, and signed.

4. Applications, resumes, transcripts, letters of reference and other information submitted will become the property of First Alliance Healthcare of Ohio and cannot be returned.
EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
It is the policy of First Alliance Healthcare of Ohio to hire only those persons who are lawfully authorized to work in the United States. As a condition of employment, individuals hired by the First Alliance Healthcare of Ohio are required to present proof of identity and of their legal eligibility to work in the United States.
Date

MonthDayYear
Date
Birthdate

MonthDayYear
Date
Number
Name
Present Address
City
State
Zip Code
Phone Number
Email Address
example@example.com
Position Title
EDUCATION
Check highest level completed.
High School

101112GED
College

1234
Grad School

1234
High School / GED
Attended From

MonthDayYear
Date
Attended To

MonthDayYear
Date
Graduate

YesNo
Semester / Quarter Hours
Type of Degree or Diploma
College / University
Attended From

MonthDayYear
Date
Attended To

MonthDayYear
Date
Graduate

YesNo
Semester / Quarter Hours
Type of Degree or Diploma
Major
Minor
Graduate or Professional School
Attended From

MonthDayYear
Date
Attended To

MonthDayYear
Date
Graduate

YesNo
Semester / Quarter Hours
Type of Degree or Diploma
Major
Minor
Vocational / Technical School
Attended From

MonthDayYear
Date
Attended To

MonthDayYear
Date
Graduate

YesNo
Semester / Quarter Hours
Type of Degree or Diploma
Major
Minor
List specific courses workshops training or rotations you have had that are related to the position for which you are applying
SKILLS
Check the following skills, experiences, etc., which you have.
TypeSign LanguageForeign LanguageOther
Type (wpm)
Foreign Language
Other
FOR SUPERVISORY/MANAGEMENT POSITIONS ONLY
Indicate the type (i.e. professional, technical, clerical, service, etc.) and number of employees you have supervised*

Employee Counseling/CoachingStatistical AnalysisBudget Preparation/MaintenanceEmployee Selection/DismissalEmployee Performance EvaluationSchedulingStaff TrainingContract NegotiationsWork AssignmentOral PresentationReport PreparationsWork Planning / Coordination
Number of Employees
List fields of work for which you have been registered, licensed or certified.
Registration
State
No
Exp Date

MonthDayYear
Date
Registration
State
No
Exp Date

MonthDayYear
Date
List memberships in employment related professional or technical societies
EMPLOYMENT HISTORY
Using a separate section for each position, describe in detail all work experiences beginning with your present or most recent job. Include periods of unemployment, self-employment, military service, internships, and volunteer and summer work. Use additional "Continuation Sheets" if necessary. Be sure to indicate whether employment was full-time or part-time, and if part- time, state the average number of hours worked per week. Incomplete information will result in the disqualification of your application.
May we contact your present employer?

YesNoPlease wait until I am a finalist.
Employer (present or most recent)
Type of Organization
Job Title
Name of Supervisor
No. Supervised by You
Phone Number
Address
Date Employed

MonthDayYear
Date
Starting Salary
per
Ending Salary
per
Reason for Leaving
Date Separated

MonthDayYear
Date
Full-time Years
Full-time Months
Part-time Years
Part-time Months
If part-time, number of hours per week
Job Duties (be specific)
Employer (present or most recent)
Type of Organization
Job Title
Name of Supervisor
No Supervised by You
Phone Number
Address
Date Employed

MonthDayYear
Date
Starting Salary
per
Ending Salary
per
Reason for Leaving
Date Separated

MonthDayYear
Date
Full-time Years
Full-time Months
Part-time Years
Part-time Months
If part-time, number of hours
Job Duties be specific
Employer (present or most recent)
Type of Organization
Job Title
Name of Supervisor
No Supervised by You
Phone Number
Address
Date Employed

MonthDayYear
Date
Starting Salary
per
Ending Salary
per
Reason for Leaving
Date Separated

MonthDayYear
Date
Full-time Years
Full-time Months
Part-time Years
Part-time Months
If part time, number of hours per week
Job Duties (be specific)
Employer (present or most recent)
Type of Organization
Job Title
Name of Supervisor
No Supervised by You
Phone Number
Address
Date Employed

MonthDayYear
Date
Starting Salary
per
Ending Salary
per
Reason for Leaving
Date Separated

MonthDayYear
Date
Full Time Years
Full Time Months
Full Time Months
If part-time, number of hours per week
Job Duties (be specific)
Employer (present or most recent)
Type of Organization
Job Title
Name of Supervisor
No Supervised by You
Phone Number
Address
Date Employed

MonthDayYear
Date
Label
per
Label
per
Reason for Leaving
Date Separated

MonthDayYear
Date
Full-time Years
Full-Time Months
Part-time Years
Part-time Months
If part-time, number of hours per week:
Job Duties be specific
Employer (present or most recent)
Type of Organization
Job Title
Name of Supervisor
No Supervised by You
Phone Number
Address
Date Employed

MonthDayYear
Date
Starting Salary
per
Ending Salary
per
Reason for Leaving
Date Separated

MonthDayYear
Date
Full-time Months
Full-time Months
Part-time Years
Part-time Months
If part-time, number of hours per week:
Job Duties (be specific)
Employer (present or most recent)
Type of Organization
Job Title
Name of Supervisor
No Supervised by You
Phone Number
Address
Date Employed

MonthDayYear
Date
Starting Salary
per
Ending Salary
per
Reason for Leaving
Date Separated

MonthDayYear
Date
Full-time Years
Full-time Months
Part-time Years
Part-time Months
If part-time, number of hours per week:
Job Duties (be specific)
Do you now work for FIRST ALLIANCE HEALTHCARE OF OHIO?

YesNo
Are you related, by blood or marriage, to any persons now working at FIRST ALLIANCE HEALTHCARE OF OHIO?

YesNo
If yes give name relationship to you and the department where employed
Have you worked under any other names? (Required for verifying education, work records, and references).

YesNo
If yes, please give list
Type a question

Permanent Full-timePermanent Part-timeWork involving travelTemporary Full-timeTemporary Part-timeAny of the precedingShift or Split Shift Work
If you are not available for work now, enter the earliest date you could begin work (month/day/year)

MonthDayYear
Date
Have you ever been convicted of any crime under the name you used on this application or under any other name? (Omit traffic violations with fines of $50 or less)

YesNo
If yes, please explain when where and disposition of case NOTE The existence of a criminal record does not automatically eliminate you from considerations
List individuals familiar with your capabilities. Do not list relatives or supervisors previously noted under employment.

REFERENCES

	Name	Years Known	Organization Position	Home/Business Address	Home/Business Phone
Reference 1
Reference 2
Reference 3
Reference 4

Certification
I certify, to the best of my knowledge and belief, that the statements given above truly represent my background and experience. I understand that if I have knowingly misrepresented, omitted, or falsified any of the application information, I will be disqualified for employment consideration or dismissed from employment with the First Alliance Healthcare of Ohio. Further, I understand that as a condition of employment, I may be required to undergo testing for controlled substances. In addition, I hereby authorize my current and former employers (including the U.S. Government or U.S. Military), personal references, registration and licensing boards, and educational institutions listed on my application for employment, to provide First Alliance Healthcare of Ohio with any job-related information requested. I also permit First Alliance Healthcare of Ohio to conduct a police and court records investigation of my background if relevant to the job for which I am applying. Notwithstanding any provisions of Federal or State law, I expressly waive any right I may have to review confidential material or information received by the First Alliance Healthcare of Ohio from a previous employer or educational institution.
Finally, I attest, under penalty of perjury, that I am legally authorized to work in the United States, and that, if I am a male between the ages of 18-26, I (please check) have/have not registered for selective service.

HaveHave Not
Applicants Name
Date

MonthDayYear
Date
Should be Empty:

EMPLOYMENT APPLICATION

PLEASE READ AND FOLLOW INSTRUCTIONS CAREFULLY

EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

EDUCATION

SKILLS

FOR SUPERVISORY/MANAGEMENT POSITIONS ONLY

EMPLOYMENT HISTORY

Certification