Application for Employment

Full Name *

First

Last

Position Desired (1st Choice) *

Position Desired (2nd Choice)

Hourly Rate Desired *

Are you seeking *

Full Time
Part Time
Pool

Date You Can Start *

What shift are you interested in? *

1st Shift
2nd Shift
3rd Shift

Can you work overtime, including weekends? *

Yes
No

Personal Information

(Incomplete information could disqualify you from further consideration.)

Address *

Address Line 1

City

State

Zip Code

Today’s Date *

Primary Phone *

Alternate Phone

Email Address *

How long have you lived at the above address? *

Are you legally authorized to work in the United States? *

Yes
No

If you have worked under another name(s) Please indicate

Referral Source

How did you hear about us?

Advertisement
Website
Referring Employee
Other

Have you ever worked for Oakview? *

Yes
No

Do you know anyone who works for Oakview? *

Yes
No

Do you have any relatives currently working for Oakview? *

Yes
No

Background

Are you currently employed? *

Yes
No

Have you ever been terminated from employment or asked to resign by an employer? *

Yes
No

Have you ever been convicted of a felony offense? *

Yes
No

(A conviction will not necessarily disqualify you for employment. Rather, such factors as - date of conviction, seriousness and nature of the crime will be considered.)

Employment History

Include your last three positions (or your last ten(10) years of employment history), including periods of unemployment, starting with the most recent and working backwards in time. (Incomplete information could disqualify you for further consideration.)

Current or Most Recent Employer

Employed From *//

Employed To *//

Starting Salary *

Ending Salary *

Company Name *

May we Contact? *

Yes
No

Company Address *

Address Line 1

City

State

Zip Code

Position Title *

Nature of the Work Performed and Position Responsibilities: *

Reason for Leaving *

Second Most Recent Employer

Employed From (2nd) //

Employed To (2nd)//

Starting Salary (2nd)

Ending Salary (2nd)

Company Name (2nd)

May we Contact? (2nd)

Yes
No

Company Address (2nd)

Address Line 1

City

State

Zip Code

Position Title (2nd)

Nature of the Work Performed and Position Responsibilities (2nd):

Reason for Leaving (2nd)

Third Most Recent Employer

Employed From (3rd)//

Employed To (3rd)//

Starting Salary (3rd)

Ending Salary (3rd)

Company Name (3rd)

May we Contact? (3rd)

Yes
No

Company Address (3rd)

Address Line 1

City

State

Zip Code

Company Phone (3rd)

Position Title (3rd)

Supervisor's Name (3rd)

Supervisor's Title (3rd)

Nature of the Work Performed and Position Responsibilities (3rd):

Reason for Leaving (3rd)

Education

High School

Name of High School *

City/State *

# of Years Attended *

Subjects Studied *

Degree/Diploma *

College or University

Name of College or University

City/State

# of Years Attended

Subjects/Major

Degree

Graduate School

Name of Graduate School

City/State

# of Years Attended

Subjects/Major

Degree

Trade or Business School

Name of Trade or Business School

City/State

# of Years Attended

Subjects/Major

Degree

Licenses or Certifications

1st License or Certification

1st License or Cert Name/Type

1st License or Cert Issued By

1st License or Cert Issue Date

1st License or Cert Expiration Date

2nd License or Certification

2nd License or Cert Name/Type

2nd License or Cert Issued By

2nd License or Cert Issue Date

2nd License or Cert Expiration Date

3rd License or Certification

3rd License or Cert Name/Type

3rd License or Cert Issued By

3rd License or Cert Issue Date

3rd License or Cert Expiration Date

List any special skills, experience and/or training that would enhance your ability to perform for the position applied for: *

List any Equipment and/or Computer skills that relate to the position that you are applying for: *

References

(Provide names/phone numbers of three persons, not related to you, whom you have known for at least three (3) years.)

First Reference

1st Reference Full Name *

1st Reference Phone *

1st Reference Occupation *

1st Reference Number of Years Known *

Second Reference

2nd Reference Full Name *

2nd Reference Phone *

2nd Reference Occupation *

2nd Reference Number of Years Known *

Third Reference

3rd Reference Full Name *

3rd Reference Phone *

3rd Reference Occupation *

3rd Reference Number of Years Known *

Driving Positions

Are you applying for a driving position? *

Yes
No

Acknowledgement

It is the policy of Oakview Medical Care Facility to provide equal employment to all qualified persons without regard to citizenship, race, color, creed, religion, gender, sexual orientation, age, national origin, marital status, disability, or veteran status. This application will be given every consideration, but its receipt does not imply that there are any open positions or that the applicant will be employed. Only applicants meeting the minimum requirements for a position as determined by the company will be considered for employment. Should more than one qualified person make application, Oakview reserves the right to select the applicant that, in its opinion, possesses the best qualifications.

Authorization

I attest with my signature below that I have read all of the above statements and understand the same and that all statements made by me are true and accurate to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that any false statements or material omissions may be grounds for refusal to hire, or for immediate dismissal. I certify that I am at least 18 years of age and am legally authorized to work in the United States. Additionally, I understand that nothing contained in the employment application or in the granting of an interview is intended to create an employment contract between myself and the Oakview for either employment or for the providing of any benefit. I authorize investigation of all statements contained in this application and hereby authorize previous employers, personal references named, or any other person(s) to whom the Facility may refer, to give any and all information regarding my background if requested. I release such persons and organizations from any legal liability in making such statements.

Applicant Name *

By entering your name in this box, you are virtually signing this application and agreeing to the above statements.

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