Date *

    First Name *

    Middle Name *

    Last Name *

    Date of Birth *

    Email *

    Home Phone

    Cell Phone

    Address *

    Position Applied For

    We are pleased that you are interested in employment with us. We offer equal opportunities to all persons without regard to race, color, religion, age, sex, national origin, disability or veteran status. Please complete this application form in ink in your own handwriting. Answer all questions fully since all statements made by you will be checked for accuracy. We will give this application every consideration, however, accepting it does not imply a commitment of employment.

    Personal Information

    Date Available for Employment

    Type of Employment?Full TimePart TimeTemporary

    If applying for a part-time position:

    DaysMondayTuesdayWednesdayThursdayFridaySaturdaySunday

    Hours from a.m. to p.m.

    Are there any days or schedules that you would not be available to work on a regular basis?

    Have you ever been employed by us? YesNo

    If Yes, when?

    Are you presently employed? YesNo

    If now employed, does your employer know of your plans to change employment? YesNo

    May we contact your present employer? YesNo

    Why do you desire to make a change in employment at this time?

    Have you ever been discharged or asked to resign from a position? YesNo

    If so, explain:

    Have you ever been convicted of, plead guilty or no contest to, a crime, other than a minor traffic violation? (an affirmative answer will not be an absolute bar to employment) YesNo

    If yes, state details (date, court, offense place of occurrence)

    Have any criminal charges (either felony or misdemeanor) been made against you which are currently pending? YesNo

    If so, explain:

    Have you ever been ineligible for, excluded from, or prohibited from participation in the Medicare or Medicaid programs, or any other federal health program? YesNo

    Do you have steady transportation to work? YesNo

    If applying for a position requiring the driving of a motor vehicle, do you have a valid license for the type vehicle to be operated? YesNo

    If so, Expiration Date
    License number:
    State of issuance:

    Education

    High School

    Completed? YesNo

    Year:

    Vocational or Bus. School

    Completed? YesNo

    College

    Completed? YesNo

    Graduate School

    Completed? YesNo

    Other (Specify)

    Completed? YesNo

    Describe any other specialized professional training (such as technical, correspondence, or night school courses):

    License & Certifications

    List all licenses and certifications you hold relating to the provision of healthcare, and state the license/certification number, state of issuance, and whether it is valid and unrestricted.

    License/Certification

    State of Issuance

    Valid and Unrestricted?YesNo

    For any license or certification you listed above, have you ever received a censure or reprimand from the licensing board? YesNo

    References

    List personal references (Do not include relatives or former employers)

    1. Name

    Address

    Phone

    2. Name

    Address

    Phone

    Work History

    Starting with present or most recent job, list all previous employers. Include self-employment, summer and part-time jobs.

    1. Name of Employer

    Address

    Phone

    Immediate Supervisor

    Date Hired

    Job Duties

    Date Left

    Reason for leaving

    2. Name of Employer

    Address

    Phone

    Immediate Supervisor

    Date Hired

    Job Duties

    Date Left

    Reason for leaving

    3. Name of Employer

    Address

    Phone

    Immediate Supervisor

    Date Hired

    Job Duties

    Date Left

    Reason for leaving

    4. Name of Employer

    Address

    Phone

    Immediate Supervisor

    Date Hired

    Job Duties

    Date Left

    Reason for leaving

    By inputting your name below, you certify that all statements made by you on this application are true and complete to the best of your knowledge and that you understand that misrepresentations, omissions, or incorrect information on this application is grounds for disqualification from further consideration or for termination from employment.

    Additionally, by inputting your name below you acknowledge that you have a continuing obligation to update this application and all statements you have made on it. Even if the information on the application is complete at the time you finish it, if additional information becomes available at a later date which relates to a question on the application, you have a continuing obligation to supplement the information on the application. Similarly, if a statement made on the application when you originally completed it is true, but becomes untrue at a later date, you have a continuing obligation to correct your answer to the question on the application at a later date. If an answer was true at the time you made it, but becomes untrue at a later date, you have a continuing obligation to correct your original answer. Failing to update your employment application with correct and truthful information may result in termination from employment.

    By inputting your name below, you understand that nothing contained in this application or in the interview process is intended to create an employment contract between IHS and you. Should this application result in your employment, you have a right to terminate your employment at any time and for any reason and IHS retains a similar right.

    I hereby acknowledge that I have read and understand each of the above statements.

    Name