Federal laws require that employers hire only individuals who are authorized to be lawfully employed in the United States. In compliance with such laws, CHSI will verify the status of every individual offered employment with CHSI. In this connection, all offers of employment are subject to verification of the applicant's identity and employment authorization, and it will be necessary for you to submit such documents as are required by law to verify your identification and employment authorization. * = Required Fields Position Applied For: Date: Collier Health Serives (CHS) considers all applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or status as a Vietnam-era or special disabled veteran in accordance with federal law. In addition, CHS complies with applicable state and local laws prohibiting discrimination in employment in every jurisdiction in which it maintains facilities. CHS also provides reasonable accommodation to individuals with a disability in accordance with applicable laws. Name: * Social Security Number: Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Email Address: * Phone: Referred by: Are you over age 18? Yes No If not, state your age If under 18, do you have a working papers? Yes No Do you want to work: Full Time Part Time If part time, specify days and hours: Are you willing to work overtime as necessary? Yes No Date you can start: Salary desired: Have you ever been employed by us? Yes No If yes, when? At what location? Is there anything that would prevent you from performing in a reasonable and safe manner the activities involved in the position for which you have applied? Yes No If yes, please explain: Have you ever been convicted of a crime? Yes No If yes, state nature of offense, when, where, and disposition: A conviction record will not necessarily be a bar to employment. This information will be used only for job-related purposes and only to the extent permitted by applicable law. Are you currently authorized to work for all employers in the United States on a full-time basis or only for your current employer? All employers Current employer only State name of any relative in our employ Record of Education Entry 1 School: Name and Address of School: Course of Study: Number Years Completed Did you Graduate? Diploma or Degree Received Entry 2 School: Name and Address of School: Course of Study: Number Years Completed Did you Graduate? Diploma or Degree Received Entry 3 School: Name and Address of School: Course of Study: Number Years Completed Did you Graduate? Diploma or Degree Received Military Service Record Have you ever served in the U.S. Armed Forces? Yes No List duties in the Service, including special training, that is relevant to the position for which you have applied. Language Skills Do you speak or write in a language other than English? Language spoken: Language written: Skills (that you believe are related to the job for which you are applying) Shorthand w.p.m. Typing w.p.m. Other office equipment Are there any other experiences, skills, or abilities that you feel especially qualify you for work with our company? Prior Work History (List in order with current or last employere first.) Account for your entire employment history and for any gaps in your employment. Entry 1 Dates: From To Name, Address and Telephone Number of Employer Rate of Pay Start Finish Supervisor's Name/Title Reason for Leaving Entry 2 Dates: From To Name, Address and Telephone Number of Employer Rate of Pay Start Finish Supervisor's Name/Title Reason for Leaving Entry 3 Dates: From To Name, Address and Telephone Number of Employer Rate of Pay Start Finish Supervisor's Name/Title Reason for Leaving Personal References (excluding relatives) Reference 1 Name and Occupation: Dates Known Address Telephone Reference 2 Name and Occupation: Dates Known Address Telephone Reference 3 Name and Occupation: Dates Known Address Telephone I understand and voluntarily agree to the Pre-employment Statement Signature: Date: • Overview • Job Opportunities • Printable Application Form • Online Application Form • Preemployment Statement © Copyright All Rights Reserved Site Design and Programming by: Exploritech, Inc. Recommended by: