Application for Employment If you would prefer to download our Application for Employment, please email your completed form to info@danielsmemorialhealthcare.org. ALL POTENTIAL EMPLOYEES ARE EVALUATED WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, AGE, MARITAL OR VETERAN STATUS, THE PRESENCE OF A NON-JOB RELATED HANDICAP OR ANY OTHER LEGALLY PROTECTED STATUS. Position Sought * How did you learn about the position? Applicant Information Name * Date * Address * City * State * Zip * Home Phone * Office Phone Other Phone Email Address * On what date would you be available for work? Are you a U.S. citizen, or are you otherwise authorized to work in the U.S. without any restrictions? * YesNo Have you ever been convicted of a felony? * YesNo If yes please describe the circumstances Have you ever been involuntarily terminated or asked to resign from any position of employment? * YesNo If yes please describe the circumstances Education (School 1) School Name Location Years Attended Degree Received Major (School 2) School Name Location Years Attended Degree Received Major (School 3) School Name Location Years Attended Degree Received Major (School 4) School Name Location Years Attended Degree Received Major Other training, certificates, or licenses held List other information pertinent to the employment you are seeking PROFESSIONAL REFERENCES (Individuals who can provide job related reference information.) (Reference 1) Name Occupation Organization Phone Address (Reference 2) Name Occupation Organization Phone Address Emergency Contact Important! Give name and address of person to notify in case of emergency. Name * Phone Number * Address * Employment (Most Recent First) (Position 1) Employer Job Title Dates Employed Position Held Address City State Zipcode Phone Supervisor Starting Salary Ending Salary Duties Performed Reason for Leaving (Position 2) Employer Job Title Dates Employed Position Held Address City State Zipcode Phone Supervisor Starting Salary Ending Salary Duties Performed Reason for Leaving (Position 3) Employer Job Title Dates Employed Position Held Address City State Zipcode Phone Supervisor Starting Salary Ending Salary Duties Performed Reason for Leaving I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed six months. 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. I hereby 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 change is specifically acknowledged in writing by an authorized executive of this organization. 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. Signature * Type Name * Date *