Primary, Dental, and Behavioral Health

PLEASE READ CAREFULLY
Note: Fields marked with a * require an answer. Please use "N/A" for "not applicable" if necessary. Applicants may be required to complete and sign a paper application for employment upon interview.
Attach Resume:
*Email:
Applying for:

Applicant Information

*First Name:
*Last Name:
MI:
*Address:
Apartment/Unit #
*City
*State
*Zip
*Phone:
Referred By:
Date Available:
Salary Expected:
I can work:
 Weekends    Evening    Night
U.S. Citizen:
   Yes    No
If not, are you authorized to work in the U.S.?:
 Yes     No
Languages Spoken:
*Have you ever worked for this company?:
 Yes   
 No
If yes, when?:
------ To ------
*Have you ever been convicted of a felony?
(By company policy some misdemeanors may bar employment):
 Yes   
 No
If yes, explain briefly:


Education

High School:
Address:
Graduate:
Yes No
Degree:
College:
Address:
Graduate:
Yes No
Degree:
Other:
Address:
Graduate:
Yes No
Degree:

References

Please list three references not related to you, whom you have known at least one year.
Name:
Occupation:
Company:
Day Phone Numbers:
Address:
Name:
Occupation:
Company:
Day Phone Numbers:
Address:
Name:
Occupation:
Company:
Day Phone Numbers:
Address:

Employment History

Company Name:
Complete Address
(w/ City, State, Zip):
Phone:
Supervisor:
Job Title:
Responsibilities:
Starting Salary:
Ending Salary:
Start Date:
(mm/dd/yyyy)
 
End Date:
(mm/dd/yyyy)
 
Reason for Leaving:
May we contact your previous employer for a reference?
 Yes    No



Military Service

Start Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
Branch:
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:

Applicant's Statement

Notification and Agreement

I certify that I have fully and accurately answered all questions and have given all information requested in this application for employment, and I understand that any wrong or incomplete information on the form may disqualify me for further consideration for employment or, if discovered after I am hired, may be grounds for my immediate dismissal. I understand that all such information is subject to verification by the company, and hereby give my consent to the Company to investigate my background and qualifications using any means, sources, and outside investigators at its disposal. I agree to undergo any type of drug and/or alcohol testing that the Company may require at any time. Finally, I understand that submission of this application does not necessarily mean that I will be hired, and that if I am hired, my employment will be at will, and either I or the Company may terminate my employment at any time, with or without notice or reason.

Signature below verifies you have read the above notice and understand what it means.




Submit