Eligibility & Availability
Please Read Carefully & Initial In the Box Next to Each Paragraph.
Applicant's Statement
Reference #1
Please list three references. Do not include family members or past supervisors.
References
 Description of Work Performed:
 Description of Work Performed:
Previous Employer #1

List below all present and past employers starting with your most recent employer first. Include any military service assignments and volunteer activities. Exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status. Account for all periods of unemployment. You must complete this section even if sending a resume.

Employment Experience
If yes, state reason(s), date of revocation or suspension and date of reinstatement below.
Has your license/certification ever been revoked or suspended? Yes No

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

 If yes, state the nature of the crime(s), when and where convicted and the disposition of the case.
Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? Yes No
If hired, would you have a reliable means of transportation to and from work? Yes No
Are you available for work overtime if necessary? Yes No
Are you available for work on weekends? Yes No

Answer the following questions only if you are applying for a field or communications center position that requires certification or licensure. If you are not appling for a field or communications position that requires certification or licensure, skip this section and continue on to the Employment Experience section.

Positions Requiring Certification or Licensure

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants / employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and ability tests.)

If no, describe the functions that cannot be performed below.:

Before answering the next question, you may first wish to review the activities description for the position which you are appliying for. This description is contained within the position description located on the job descriptions page. Click here to go to the job descriptions page.

After you have reviewed the required activities of the position you are applying for, you may return to this page and continue completing your application.

If you are familiar with the required activities of the position you are applying for and do not wish to consult our job descriptions page, please answer the next question and continue completing your application.

 State any other information you feel may be helpful to us in considering your application:
If yes, which language?:
Additional Information
 If so, please describe any job related training received in the U.S. Military:
Military Service
Education
 (Note: Proof of citizenship or immigration status will be required upon employment)
If you are under 18 years of age, can you provide required proof of your eligibilty to work?
ONLINE APPLICTION FOR EMPLOYMENT
           
E-Mail:
Name:
Applicant Name and E-Mail Address
 
Have you ever been employed with us before?
Yes:
No
Are you currently employed?
Yes:
No
If, so, may we contact your employer?
Yes:
No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Yes No

What date are you available for work?
What is your desired salary range?
Are you available to work:  (Check all that apply.) Regular, Full-Time Work
Regular, Part-Time Work
Temporary Work, e.g., Summer/Holiday Work
School Name and Address # of Years Completed Did You Graduate? Degree or Diploma
High School Yes
No
College/
University 		Yes
No
Vocational/
Business 		Yes
No
Health Care Yes
No
Have you obtained any special skills or abilities as the result of service in the military? Yes No
Position Desired
Position Applying For:
If you are applying for a position not listed above and you selected the "Other" Option, please indicate the postion you are for below:
Personal Information
Present Address:
City:
Home Phone
Business Phone
Social Security #:
State:
Best time to contact you:
Message Phone:
Driver's License #:
Zip:
Referral Sourse
How did you learn of us?

If you were referred to us from a source not listed above and you selected the "Other" Option, please indicate the other referral source below

Many of our customers (patients) do not speak English. Do you speak, write or understand any foreign languages? Yes No
 
Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? Yes No
Are you licensed/certified for the job applied for? Yes No
Name of license/certification:
Issuing :Agency / State 
License/certification number
Name of license/certification:
Issuing Agency / State: 
License/certification number
Employer Name: Telephone #:
Address: Dates of Employment:
City, State, Zip: Starting Hourly Rate of Pay:
Type of Business: Final Hourly Rate of Pay:
Supervisor: Starting/Present Job Title:
Reason for leaving:
May we contact this employer for a reference? Yes No N/A
Previous Employer #2
Employer Name: Telephone #:
Address: Dates of Employment:
City, State, Zip: Starting Hourly Rate of Pay:
Type of Business: Final Hourly Rate of Pay:
Supervisor: Starting/Present Job Title:
Reason for leaving:
May we contact this employer for a reference? Yes No N/A
Previous Employer #3
Employer Name: Telephone #:
Address: Dates of Employment:
City, State, Zip: Starting Hourly Rate of Pay:
Type of Business: Final Hourly Rate of Pay:
Supervisor: Starting/Present Job Title:
Reason for leaving:
 Description of Work Performed:
May we contact this employer for a reference? Yes No N/A
Name: Years Known:
Address:
City, State, Zip:
Occupation:
Telephone #: Best Time to Call:
Reference #2
Name: Years Known:
Address:
City, State, Zip:
Occupation:
Telephone #: Best Time to Call:
Reference #3
Name: Years Known:
Address:
City, State, Zip:
Occupation:
Telephone #: Best Time to Call:

Type Initial
 I certify that the answers given herein are true and complete.
Type Initial
 I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
Type Initial
 This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.
Type Initial
 I herby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such changes is specifically acknowledged in writing by an authorized executive of this organization.
Type Initial
 In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
Applicant's Certification
By typing your name below and submitting this application, you certify that all the information provided is accurate and correct, and you acknowledge that any falsification is grounds for dismissal.
Date:
Enter Your Full Name