Immanuels HealthCare Center

Submit Application

Record of Employment

1. Current/Most Recent Employer
Company Name:
May we contact?	Yes No
Telephone:
Your Starting Position:
Your Last Position:
Months In Last Position:
Address:
City:
State:
Zip:
Dates Employed:	From To (ex: MM/YYYY)
Rate of Pay:	Start End
Supervisor's Name & Title:
Reason For Leaving:
Your Duties:
2. Next Previous Employer
Company Name:
May we contact?	Yes No
Telephone:
Your Starting Position:
Your Last Position:
Months In Last Position:
Address:
City:
State:
Zip:
Dates Employed:	From To (ex: MM/YYYY)
Rate of Pay:	Start End
Supervisor's Name & Title:
Reason For Leaving:
Your Duties:
3. Next Previous Employer
Company Name:
May we contact?	Yes No
Telephone:
Your Starting Position:
Your Last Position:
Months In Last Position:
Address:
City:
State:
Zip:
Dates Employed:	From To (ex: MM/YYYY)
Rate of Pay:	Start End
Supervisor's Name & Title:
Reason For Leaving:
Your Duties:
4. Next Previous Employer
Company Name:
May we contact?	Yes No
Telephone:
Your Starting Position:
Your Last Position:
Months In Last Position:
Address:
City:
State:
Zip:
Dates Employed:	From To (ex: MM/YYYY)
Rate of Pay:	Start End
Supervisor's Name & Title:
Reason For Leaving:
Your Duties:

Education

Skills and Qualifications

Please indicate your proficiency in the following:

Adding Machine (10 Key)

Data Entry

Personal Computer

Word Processor

WPM:

Software Skills:

List additional skills and qualifications:

References

Work Reference #1:
Name:		Company:
Address:		Telephone:
Work Reference #2:
Name:		Company:
Address:		Telephone:
Work Reference #3:
Name:		Company:
Address:		Telephone:

Other Information

Have you ever pled guilty, or no contest to, or been convicted of, a misdemeanor or felony? Yes No
If Yes, please give the date(s) and details:

Have you been arrested for any matters for which you are out on bail or on your own recognizance pending trial? Yes No
If Yes, please give the date(s) and details:

NOTE: Answering "Yes" to these questions does not constitute an automatic bar to employment. Factors such as age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account. (Do not include minor traffic infractions, and convictions for which the record has been sealed or expunged, any conviction for which probation has been successfully completed or otherwise discharged and the case has been judicially dismissed, referrals to and participation in any pre-trial or post-trial diversion programs in answering these questions.)
Have you ever been in the Military Service? Yes No
If Yes, give type of discharge:

NOTE: A dishonorable or general discharge is not an absolute bar to employment. Other factors will affect a final decision to hire or not to hire.
Driving History - Complete this section only if it relates to one or more of the jobs for which you are applying.
State:		Class:
Number:		Expiration:
DRIVING RECORD (Last 3 Years):
Number of Tickets:		Number of Accidents:
Do You Have Automobile Liability Insurance?		Company Providing Policy:

Alternate/Emergency Contact Information

Alternate/Emergency Contact:
Alternate/Emergency Phone:

Resume

Cover Letter and/or Text Resume:
	Only .txt, .rtf, .pdf, and .doc files will be accepted.
Attach Resume - OPTIONAL:

Fair Credit Reporting Act

DISCLOSURE

As an applicant for employment or an employee of this company, you have rights under the Fair Credit Reporting Act (FCRA). By this document, this company discloses to you that a consumer report may be obtained for employment purposes as part of the preemployment background investigation and at any time during your employment, if you are hired. If this company obtains a consumer report about you, and if this company considers any information in the consumer report when making an employment related decision that directly and adversely affects you, this company will provide you with a copy of the consumer report and a summary of your rights under the FCRA before the decision is finalized. You also may contact the Federal Trade Commission about your rights under the FCRA.

AUTHORIZATION

By submitting this application, I acknowledge that I have received the foregoing disclosure that this company may obtain a consumer report as part of its preemployment background investigation and/or during the course of my employment, if I am hired. By submitting this application, I voluntarily authorize this company to obtain consumer reports about me and to consider the consumer report in its preemployment background investigation and/or when making decisions during the course of my employment, if I am hired. I understand that I have rights under the Fair Credit Reporting Act, including the rights discussed above.

EEOC Compliance

Employment Disclosure

All qualified applicants will receive consideration for employment without regard to sex, race, color, national origin or ancestry, age or disability. No information on this application will be used for the purpose of discrimination.

Submitting this application certifies that my answers to the forgoing questions are true and correct and that I understand that intentionally false information will result in refusal of employment or termination of employment if discovered after the date of hire.

I voluntarily grant this company the right to investigate and verify the information and statements I have provided in this application and agree to hold all persons harmless with respect to any information they may give, receive or verify.

I agree that, if hired, I will observe all policies and strict confidentiality concerning all affairs of this company and its members.

I hereby acknowledge and agree that 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 agreed that this "at will" employment relationship may not be changed by any written document or by conduct, unless such change is specifically agreed and acknowledged in writing by an authorized executive of this organization.

If you are asked to be interviewed, you will sign the application at that time.

By submitting this application, I affirm that I have read and agree to all of the disclosures and conditions included in the on-line application.

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High School
Name:		Major/Courses:
Last Year Completed:	1 2 3 4
Did you Graduate?	Yes No	Date Graduated:
Degree/Certificate:
College/Technical School
Name:		Major/Courses:
Last Year Completed:	1 2 3 4
Did you Graduate?	Yes No	Date Graduated:
Degree/Certificate:
Graduate Studies
Name:		Major/Courses:
Last Year Completed:	1 2 3 4
Did you Graduate?	Yes No	Date Graduated:
Degree/Certificate:
Other (specify)
Name:		Major/Courses:
Last Year Completed:	1 2 3 4
Did you Graduate?	Yes No	Date Graduated:
Degree/Certificate:

This company is dedicated to a policy of affirmative action and equal opportunity in employment without regard to race, religion, gender, sexual orientation, national origin, age, veteran or disabled status, or any other protected class. Reasonable accommodation will be made as appropriate to enable any employee or applicant for employment to safely and properly perform the job applied for as requested and as appropriate. The following information is necessary for this company to evaluate its hiring practices and to track its progress and effectiveness in complying with its Affirmative Action Plan and equal employment policies. The information is voluntary and will be kept confidential insofar as possible. Information provided will not be negatively considered in any part of the selection process. PLEASE CHECK THE APPROPRIATE BOXES AND COMPLETE THE FOLLOWING ENTRIES
Sex:	Male Female
Age:
Date of Birth:
Ethnic Background:
	Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
	American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
	Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
	Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
	White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
	Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
	Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.
Veteran Status:
	VIETNAM ERA VETERAN - A person who has served more than 180 days of active duty from August 5, 1964 to May 7, 1975.
	DISABLED VETERAN - A person entitled to disability compensation by the Veteran's Administration for disability at 30% or more, whose discharge was for a disability incurred in the line of duty.
Disabled Status:
	If you have a physical or mental disability, you must qualify as a disabled person as defined by federal law (e.g., Americans with Disabilities Act).