COVID Vaccination

Work Desired

Work History

List your present or most recent employer first. Include military service if among last four jobs. Give dates of unemployment if applicable. You may list
Volunteer experience if you do not have paid work experience. (Please list a “V” in the Salary column)

(1)

(2)

(3)

All references may be checked, including my present employer.

Education

High School

College

Other/Specify

Licensure

Complete the following section if the position for which you are applying for requires a license, certification, or registration of any kind. List any additional licenses that you may posses as well.

(1)

(2)

(3)

Please give us any additional information you feel would be useful to us (include honors received, volunteer or community services, special qualifications, memberships in professional organizations or other information you feel is related to your application for the position for which you are applying.

Please Read Carefully

I certify that the information contained in this application is correct to the best of my knowledge and understand that falsification of this information is grounds for refusal to hire, or if hired, dismissal.

Except as noted otherwise above, I authorize any of the persons or organizations references in this application to give you any and all information concerning my previous employment, character and general reputation, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application and release all such parties from all liability for any damage that may result from furnishing such information to you. I authorize you to request and receive such information. The Company completes a background check, 3-year MVR, and drug test on all potential employees.

I understand that it is important that I am at work when scheduled and therefore I am responsible to make the necessary transportation arrangement to ensure that I am at work on time and as scheduled.

In the interest of safety and health of our patients and employees, employment is subject to a successful health screening and/or physical if required by law or dictated by the physical demands of the specific job.

I understand that no representative of the Company has any authority to enter into any agreement for employment for any specified period. Also, I understand that if hired I will have entered my employment with the Company voluntarily and that I will be free to resign at any time with or without reason. Similarly, the Company may terminate employment at any time with or without reason.

I agree to conform to the employer’s drugs in the workplace policy and agree to submit to initial and any random drug test as required by the employer.

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