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
