Employment Application

Employment Desired

Position Desired *

Hourly Rate Desired

Are you seeking: *Full timePart timeTemporary

Date you can start *

Personal Information

Name *

Email Address *

Home Phone *

Cell Phone

Are you eligible to work in the United States? *YesNo

Are you at least 18 years of age or older? *YesNo(If no, you may be required to provide authorization to work.)

Can you work weekends?YesNo

Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accomodation? *YesNo(If you are unsure of essential functions, please ask to review a job description.)

Background

Are you currently employed? *YesNo

(If yes, may we contact your present employer?)YesNo

Have you ever been terminated from employment or asked to resign by an employer? *YesNo

(If yes, please provide company names and contacts.)

Have you ever been convicted of a felony offense? *YesNo

(If yes, please provide details and locations for all convictions.)

Employment History

Include your last three positions (or your last ten (10) years of employment history), including periods of unemployment, starting with the most recent and working backwards in time. (Incomplete information could disqualify you from further consideration.)

Current or Most Recent Employers

Employer

Company Name

Phone Number

Street Address

Apartment, suite, etc

City

State

ZIP / Postal Code

Country

Employed From:

Employed To:

Starting Salary

Ending Salary

Supervisor Name

Supervisor Title

Nature of the Work Performed/Job Responsibilities

Reason for Leaving

Education Background

High School

High School Name

City and State

Number of Years Attended

Diploma obtained?YesNo

College/University

College or University Name

City and State

Subjects/Major

Number of Years Attended

Degree obtained?YesNo

Graduate School

Graduate School Name

City and State

Subjects/Major

Number of Years Attended

Degree obtained?YesNo

Trade/Business School

Trade or Business School Name

City and State

Subjects/Major

Number of Years Attended

Degree obtained?YesNo

Licenses or Certifications

Name/Type

Issued by:

Issue date:

Expiration date:

Special skills, experience, and/or training that would enhance your ability to perform the position applied for

Equipment and/or computer skills

References

(Provide names/addresses/phone numbers of three persons, not related to you, whom you have known at least three (3) years.)

Reference

Name

Phone

Number of Years Known

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Do you know anyone who works for Coplin Health Systems?

(If yes, provide name and length of time known.)

Name

Length of Time Known in Years

Do you have any relatives currently working for Coplin Health Systems?

(If yes, provide names and relationship.)

Name

Length of Time Known in Years

How Did You Hear About Us?

Walk InAdvertisementReferralOther

Referral Name

Resume

Resume Upload

No file chosen

Acknowledgements and Authorization

ACKNOWLEDGEMENT: It is the policy of Coplin Health Systems to provide equal employment opportunity to all qualified persons without regard to citizenship, race, color, creed, religion, gender, sexual orientation, age, national origin, marital status, disability, or veteran status. This application will be given every consideration, but its receipt does not imply that there are any open positions or that the applicant will be employed. Only applicants meeting the minimum requirements for a position as determined by the company will be considered for employment. Should more than one qualified person make application, the company reserves the right to select the applicant that, in its opinion, possesses the best qualifications. In making this application for employment an investigative consumer report may be prepared whereby information is obtained through personal interviews with neighbors, friends, or other acquaintances. Such an inquiry would include information as to character, general reputation, personal characteristics, and mode of living of the applicant. An applicant has the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation.

AUTHORIZATION: Please read carefully before signing. I authorize investigation of all statements contained in this application (if I am considered for employment) and hereby authorize previous employers, personal references named, or any other person or persons to whom Coplin Health Systems may refer, to give any and all information regarding my background if requested. If employed, I agree to engage in no outside activity which would involve a material conflict of interest with, or which could, as determined by Coplin Health Systems, reflect adversely on the company. If employed, I agree to maintain confidentiality regarding any information concerning the company that may come to my knowledge. Further, I agree to comply with all of the policies and regulations of Coplin Health Systems as set forth in the company’s employee handbook or other communications distributed to all employees. I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Coplin Health Systems to hire me. I understand that if employment is offered to me, either verbally or in writing, such offer does not constitute a contract of employment. I understand that if I am employed by Coplin Health Systems, my employment will be for no definite period of time and that my employment can be terminated at any time and for any reason, with or without cause and without prior notice, at the option of either the company or myself. I also understand that this status can only be altered by a written contract of employment, specific to all material terms, that is signed by an authorized officer of Coplin Health Systems. I attest with my signature below that I have read all of the above statements and understand the same and that all statements made by me are true and accurate to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that any false statements or material omissions may be grounds for refusal to hire, or for immediate dismissal. I certify that I am at least 18 years of age and am legally authorized to work in the United States. Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between myself and Coplin Health Systems for either employment or for the providing of any benefit. I understand that as a condition of this application and any employment, I may be required to submit to testing for the presence of illegal drugs. I hereby consent to such testing. I further acknowledge that no promise or guarantee is binding upon Coplin Health Systems unless made in a written contract of employment as described above.

Applicant's Name *

Today's Date *

THIS APPLICATION IS VALID ONLY FOR 1 YEAR FROM THE DATE SIGNED/DATED ABOVE.