Application for Employment

Name

First

Last

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address If Different from Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Cell Phone

Home Phone

Position Sought:

Desired Pay Range:

Desired Payment:

Hourly
Salary
Contract

Are you currently employed?

Yes
No

Available Start Date:

Have you ever applied to or worked for SPCHS before?

Yes
No

If yes, please explain (include date):

Do you have any friends, relatives or acquaintances working for SPCHS?

Yes
No

If yes, state name & relationship:

Do you have transportation to/from work?

Yes
No

Will you relocate?

Yes
No
Not Applicable

Are you over the age of 18?

Yes
No

If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States?

Yes
No

If hired, are you willing to submit to and pass a controlled substance test?

Yes
No

Are you able to perform the essential functions of the job for which you are applying, either with/without reasonable accommodation?

Yes
No

If no, describe the functions that cannot be performed (Note: Company complies with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.):

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

Yes
No

If yes, please describe the crime - state nature of the crime(s), when and where convicted and disposition of the case. (Note: No applicant will be denied employment solely on the grounds of conviction of criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.):

Name and Location of high school education:

Did you graduate?

Yes
No

Name and Location of college or university education:

Did you graduate?

Yes
No

Degree, mayor/subjects of studies:

Name and Location of any specialized training, trade school, etc.:

Did you graduate?

Yes
No

Areas of study:

Name and Location of any other training:

Did you graduate?

Yes
No

Major/Subjects of study:

Military Service:

Please list your areas of highest proficiency, special skills or other items that may contribute to your abilities in performing this position.

Please provide the name and address of the company of your most recent employment:

Dates employed:

Your role/title:

May we contact them?

Yes
No

If yes, please provide their contact telephone number:

Please provide the tasks your performed and reason for leaving:

Please provide company name and location, dates employed, role/title, tasks performed and reason for leaving for any other previous employment:

May we contact them?

Yes
No

If yes, please provide their contact number:

List three personal references, not related to you, who have known you for more than one year.

First

Last

How long have you known them?

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone:

Home Phone:

List three personal references, not related to you, who have known you for more than one year.

First

Last

How long have you known them?

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone:

Home Phone:

List three personal references, not related to you, who have known you for more than one year.

First

Last

How long have you known them?

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone:

Home Phone:

In case of emergency, please notify:

First

Last

Relationship

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone

Home Phone

I certify that all information provided by me on this application is true and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would alter the integrity of this application. I authorize my previous employers, schools, or persons listed as references to give any information regarding employment or educational record. I agree that this company and my previous employers will not be held liable in any respect if a job offer is not extended, or is withdrawn, or employment is terminated because of false statements, omissions, or answers made by myself on this application. In the event of any employment with this company, I will comply with all rules and regulations as set by the company in any communication distributed to the employees. In compliance with the Immigration Reform and Control Act of 1986, I understand that I am required to provide approved documentation to the company that verifies my right to work in the United States on the first day of employment. I have received from the company a list of the approved documents that are required. I understand that employment at this company is "at will", which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I hereby acknowledge that I have read and understand the above statements.

First

Last

Date / Time

Date

Time

Get In Touch

OPEN

BY THE NUMBERS

(12 MONTHS)

Data: