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Application for Employment
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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
What days can you work?
*
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Next
Personal Information
(Incomplete information could disqualify you from further consideration.)
Address
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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 no, provide document title and number
*
If you have worked under another name(s) Please indicate
Next
Referral Source
How did you hear about us?
Advertisement
Website
Referring Employee
Other
Name of Referring Employee
*
Have you ever worked for Oakview?
*
Yes
No
Please provide dates, supervisors, etc.
*
Do you know anyone who works for Oakview?
*
Yes
No
Please provide name and relationship for each
*
Do you have any relatives currently working for Oakview?
*
Yes
No
Please provide name and relationship for each relative
*
Next
Background
Are you currently employed?
*
Yes
No
May we contact your present employer?
*
Yes
No
Have you ever been terminated from employment or asked to resign by an employer?
*
Yes
No
Please provide company names and contacts
*
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.)
Please provide dates and locations for all convictions
*
Next
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
*
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Starting Salary
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Ending Salary
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Company Name
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May we Contact?
*
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Company Address
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Company Phone
Position Title
*
Supervisor's Name
Supervisor's Title
Nature of the Work Performed and Position Responsibilities:
*
Reason for Leaving
*
Second Most Recent Employer
Employed From (2nd)
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Starting Salary (2nd)
Ending Salary (2nd)
Company Name (2nd)
May we Contact? (2nd)
Yes
No
Company Address (2nd)
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Company Phone (2nd)
Position Title (2nd)
Supervisor's Name (2nd)
Supervisor's Title (2nd)
Nature of the Work Performed and Position Responsibilities (2nd):
Reason for Leaving (2nd)
Third Most Recent Employer
Employed From (3rd)
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Starting Salary (3rd)
Ending Salary (3rd)
Company Name (3rd)
May we Contact? (3rd)
Yes
No
Company Address (3rd)
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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)
Next
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
Next
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:
*
Next
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
*
Next
Driving Positions
Are you applying for a driving position?
*
Yes
No
Do you have a valid driver's license?
*
Yes
No
Driver's License Number
*
Class of License
*
Have you had your driver's license suspended or revoked in the last three (3) years?
*
Yes
No
If so, please explain:
*
Next
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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