I am applying for

Personal Information

Are you at least 18 years of age? *
Do you have any relatives or friends working here? *

Position Information

Have you ever worked for this organization? *

Certification Information

List only current certifications - photocopies required at interview.

CPR & First Aid

CDL

Defensive Driving Course

Other:

Work Requirements

Can you provide proof, if hired, that you are eligible to work in the U.S.? *
Do you have a valid Driver's License? *

Have you ever been convicted, or pled guilty or no contest to a felony or misdemeanor, including a DUI/DWI or similar offense, had any moving violations, or had your license revoked or suspended?

A conviction will not necessarily disqualify you from employment.

Have you ever been excluded or are you currently excluded from participating in any federal health program such as Medicare or Medicaid? *

Employment History

I

May we contact?

II

May we contact?

III

May we contact?

Military

Past Employment

Disciplined or terminated for Fraud or a HIPAA Violation? *
Disciplined or terminated for reckless driving? *
Placed on probation or terminated for excessive absenteeism? *
Disciplined or fired for violation of safety rules? *
Disciplined or fired for assault or fighting? *
Disciplined or fired for harassment? *
Disciplined or fired for patient abuse? *
Disciplined or fired for alcohol or drug related activity at work? *
Charged with DUI and/or wreckless driving? *

Answers of Yes for any of the above questions will not necessarily disqualify you from employment.

Education and Training

High School

Did you graduate?
Have you received your GED?

College

Did you graduate?

Other College

Did you graduate?

Technical School

Did you graduate?

Other School/Training

Did you graduate?

Describe any additional qualifications or information, personal or professional, that you feel would be beneficial for us to know when considering your application