Application for Employment

First Name *

Middle Initial *

Last Name *

Email Address *

Phone Number *

Complete address: *

Position applied for: *

Are you seeking? *

How did you hear about us?

Education

High School Last Attended (Name & Address)

College or Technical School (Name & Address)

Other (Name & Address)

Special Training, Skills or Certifications (please describe)

Clinical Registration / License:

Other License or Certifications

Employment History

Employer Name & Address

If you have more employment history, upload your resume

No file chosen

PDF files only

References

Please provide at least 3 references. Please click here to download this reference form and provide one copy for each of your references authorizing us to contact them.

Questions for Applicant

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

If under age 18, can you provide required proof of eligibility to work?YesNo

Have you ever been employed here before?YesNo

Have you ever been discharged by a former employer or resigned after being told your performance was unsatisfactory?YesNo

Have you ever been convicted of a misdemeanor or felony?YesNo

(All offers of employment are conditional upon the satisfactory completion of a criminal background screening and driving record check.)

If you carry a professional license, have you ever had stipulations placed on it?YesNo

Have you ever been sanctioned by Medicare, Medicaid or Title V?YesNo

Are you related to a board or staff member?YesNo

May we contact your present employer?YesNo

May we contact your former employer(s)?YesNo

Applicant's Statement

I understand and agree that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed. Furthermore, I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause, and without prior notice. I understand that no representative of the employer has the authority to make assurances to the contrary.

I give the employer the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the employer and its representatives for seeking such information, and all other persons, corporations, or organizations for furnishing such information.

I agree

Application for Employment

Education

Employment History

References

Questions for Applicant

Applicant's Statement

Admission to Services

Accreditation

Non-Medical / Private Pay