Employment Application Form

Date / Time *

Date

Time

Social Security Number *

Name *

First

Last

Home Phone

Mobile *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Position Applied For *

Attach All Documents Here *

Click or drag files to this area to upload. You can upload up to 50 files.

If you do not have all the documents above, please tell us when it will be available

PART A: PERSONAL INFORMATION

Title: Mr. /Miss /Mrs. *

Name *

First

Last

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Correspondence Address (If different

Address Line 1

Address Line 2

City

State

Zip Code

Home Telephone *

Work Telephone *

Date of Birth *

May we contact you at work? *

Are you a citizen of the United States? *

If no, are you eligible to work in the United States? *

If you are under age 18, do you have an employment/age certificate? *

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

If yes, please explain the circumstances of the conviction.

AVAILABLE HOURS (in HH:MM format)

Monday *

Start Time

Finish Time

Tuesday *

Start Time

Finish Time

Wednesday *

Start Time

Finish Time

Thursday *

Start Time

Finish Time

Friday *

Start Time

Finish Time

Saturday *

Start Time

Finish Time

Sunday *

Start Time

Finish Time

PART B: EDUCATION AND TRAINING

1. High School Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Start Date *

End Date *

Diploma Received? *

Area of Study *

2. High School Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Start Date *

End Date *

Diploma Received? *

Professional trainings/ qualifications with dates and levels obtained

PART C: PRESENT AND PAST WORK HISTORY

Present or most recent employer *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Start Date *

End Date *

Position Held and Duties: *

Reason for leaving *

Starting Salary *

Ending Salary *

May we contact this employer? *

If no, please indicate reason. *

WORK HISTORY

1. Give details of your work history with the most recent listed first

Employer Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Start Date *

End Date *

Position Held and Duties: *

Reason for leaving *

Starting Salary *

Ending Salary: *

May we contact this employer? *

If no, please indicate reason. *

2. Give details of your work history with the most recent listed first

Employer Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Start Date *

End Date *

Position Held and Duties *

Reason for leaving *

Starting Salary *

Ending Salary *

May we contact this employer? *

If no, please indicate reason *

PART D: SUPPORTING STATEMENT

Please indicate all relevant experience, skills and work history that relate to the job description of which you have applied. Please print clearly. All illegible entries will not be considered.

(attach additional sheets here if necessary)

Click or drag a file to this area to upload.

PART E: MEDICAL HISTORY

What absences due to illness have you had from work for the last two years? *

Do you have any illness that will present you from performing the duties of the position of which you have applied? *

If yes, please indicate

Can you lift a weight of seventy pounds? *

PART F: REFERENCES

Please list three-character references of which we may contact

Name *

First

Last

Relationship *

Years of Affiliation *

Telephone number *

Name *

First

Last

Relationship *

Years of Affiliation *

Telephone number *

Name *

First

Last

Relationship *

Years of Affiliation *

Telephone number *

PART G: DECLARATION

By signing below, I, *

First

Last

Input First and Last name

on the date of * *

Input Date above

hereby certify that all information included in the above application is true and valid to the best of my knowledge. I also understand that misrepresentation or falsification of the information provided above will result in my immediate disqualification from the selection process and dismissal from any position appointed to by the Agency after discovery.

Name *

First

Last

Date / Time *

CONFIDENTIAL AGREEMENT READ CAREFULLY AND SIGN BELOW IF YOU AGREE TO THESE TERMS OF EMPLOYMENT

I agree that except at the request and for the benefit of First choice health services inc. I will not disclose to anyone or use for my own purposes any of confidential or proprietary information, either during or after my employment. I understand and agree that First choice health services inc bidding, costs, pricing and marketing information and techniques, customer names and information, and employee name and information are confidential and proprietary to First choice health services inc.

I certify that this application contains no willful misrepresentation or falsifications and that this information given by me is true and complete to the best of my knowledge and belief. I authorized First choice health services inc to contact all sources to verify the information on this application. I understand that any falsification, misrepresentation or fraudulent information provided by me in connection with my application for employment is sufficient grounds for withdrawal of an employment offer or immediate discharge.

I understand that this application is not a contract of employment.

I authorize and request my former employers, references, and educational institutions which have information about me, to give First choice health services inc any and all information and opinions about me in their possession and which may lawfully be disclosed. I hereby waive written notice of such release of information and opinions, and release such former employers, references, and educational institutions from any liability or claim relating to such release of information and opinions. I also authorized and request federal, state, and local governmental agencies to release to First choice health services inc any information requested, concerning any criminal convictions on my record. A photocopy of this signed authorization and waiver shall be valid as an original.

Signature *

Date *

CONFLICT OF INTEREST

I acknowledge that I have read the company policy statement concerning conflict of interest and I hereby declare that neither I, nor any other business to which I may be associated, nor, to the best of my knowledge, any member of my immediate family has any conflict between our personal affairs or interests and the proper performance of my responsibilities for the company that would constitute a violation of that company policy. Furthermore, I declare that during my employment, I shall continue to maintain my affairs in accordance with the requirements of said policy.

Signature *

Date *

RELEASE OF INFORMATION

I hereby authorize all prior employers, schools, credit bureaus, Social security Administration. Law enforcement agencies and investigative agencies to give First choice health services inc all information concerning my previous employment and any pertinent information they may have personal or otherwise, concerning my qualifications for the position applied for. I release to First choice health services inc and all its employees form all liability for any damage that may result from furnishing information to First choice health services inc. I also release First choice health services inc and all its employees from all liability for any damage that may result from reliance on the information furnished. I understand that if a consumer investigative report is requested, I have the right under the Fair Credit Reporting Act to request in writing, within a reasonable time, a complete and accurate disclosure of the nature and scope of the investigation. This written request should be addressed to the location where this application is filed.

Name *

First

Last

Social Security Number *

Signature of Applicant *

Date *

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