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| Applicant Name: |
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| Address: |
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| Telephone: |
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| Age: |
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Are you 18 years or older?
yes
no |
Are you a U.S. Citizen?
Are you an alien authorized
to work in the U.S.? |
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yes
no
yes
no |
| Have you ever
worked or attended school
under another name? |
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If so, under what name?
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| Have you ever been convicted
of a crime?
yes
no
If yes, give details, including date(s):
A "yes" answer will not automatically
disqualify you from employment. We will consider the nature
& date of the offense and the job for which you are
applying for job-related purposed only, and only to the
extent permitted by applicable law. |
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| Position Desired: |
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| Date you can start: |
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| Hourly Rate / Monthly Salary
Desired: |
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| Do you prefer |
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Full-time or
Part-time |
| Hours you are available to work
per week: |
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| Days of the week you are
available to work:
Are you able to work nights, weekends, and holidays? |
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Have you previously worked for
Health Providers or Van Binsbergen's & Associates? |
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yes
no |
| How did you learn about this
opening? |
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| Education |
| High School: |
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Graduated
yes
no |
| Technical School: |
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Gradated
yes
no Course of Study:
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| College / University: |
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Graduated
yes
no Course of Study:
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| Other education, training, or
skills: |
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Work
Experience
Please
list all previous employment beginning with the most recent. |
| Employer, Address, Phone: |
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| Date, Position Held, Reason for
leaving: |
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| Supervisor's Name & Title |
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| Description of Duties, Final
Pay |
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| Employer, Address, Phone: |
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| Date, Position Held, Reason for
leaving: |
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| Supervisor's Name & Title |
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| Description of Duties, Final
Pay |
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| References |
| Name: |
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| Phone: |
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| Relationship: |
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| Name: |
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| Phone: |
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| Relationship: |
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| Name: |
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| Phone: |
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| Relationship: |
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AUTHORIZATION
AND ACKNOWLEDGMENTS
I certify that the facts contained in this application are
true and complete to the best of my knowledge. I understand
that if I am employed, any false statements on this application
may be grounds for dismissal.
I authorize investigation of all statements contained in
this application. I also grant permission to contact all
references listed above, and authorize them to release all
information concerning my previous employment and any other
pertinent information these references might have, personal
or otherwise. I release all parties from all liability for
any damage that may result from furnishing this information
to you.
That any understanding and agreements between the employer
and any employee to the contrary must be in writing and
sign by the proper office of the company.
That the employee handbook does not constitute an employment
contract and may be changed or eliminated at the employer’s
discretion.
I understand and agree that, if hired, the employer retains
the right to terminate its employees at any time for any
reason not prohibited by law, that an employee has the right
to resign employment at any time for any reason, subject
to the employer’s notice request or requirement, and
that these mutual rights constitute the employer’s
at will policy
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| Applicant Signature:
Date:
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