Choice Health Care

1257 N Fairfield Rd
Beavercreek, OH  45432

Employment Application

When completed, please send to us as follows:

 * Mail or bring in to above address
* Fax:  (937)254-6292

Personal

Last Name:                           First:                                 Initial:

Social Security #                                          

Other Name(s) Used: Home Telephone #

(      )

Address: Other Telephone#

(      )

Position Applied for:


Referred by:  

Salary Desired:

Have you ever interviewed with this company or its affiliates before?

Yes:________  No:______

If yes, list date(s), job title(s), and location(s).
Have you ever been employed by this company or its affiliates before?

Yes:________  No:______

If yes, list date(s), job title(s), and location(s).
Do you have any relatives employed by this company or its affiliates?

Yes:________  No:______

If yes, list date(s), job title(s), and location(s).
Are you at least 18 years old?

Yes:________  No:______

If under 18, do you have a work permit?

Yes:________  No:______

Education

Circle Highest Grade Completed:          High School                                9    10    11    12
                                                                      College, Trade or Business      1      2      3      4
                                                                      Graduate Studies                    ______________

             School              

            Address          

         Major Studies        

      Degree, Diploma
             License or Certificate
       

High School:


                                   

                                         

                                                       

College/University:


                                   

                                         

                                                         

Vocational/Business/Other:


                                   

                                         

                                                         

List any professional designations:


Other special knowledge, skills, or qualifications:



For Clerical Applicants Only:

Do you type?:      Yes______    No:______     If yes, WPM:__________                                                                              
Computer skills (Hardware/Software):




Employment History

List all employments for the past 10 years, starting with the most recent position.  All information must be completed. You may attach a resume, but not in place of completing the required information.

Employed from:

     /     /    

Employer name:

Supervisor name:

Starting salary:

Employed until:

     /     /    

Employer Address:

Supervisor Phone #:

Ending salary:

Job title:

Reason for leaving:

Duties & responsibilities:


Employed from:

     /     /    

Employer name:

Supervisor name:

Starting salary:

Employed until:

     /     /    

Employer Address:

Supervisor Phone #:

Ending salary:

Job title:

Reason for leaving:

Duties & responsibilities:


Employed from:

     /     /    

Employer name:

Supervisor name:

Starting salary:

Employed until:

     /     /    

Employer Address:

Supervisor Phone #:

Ending salary:

Job title:

Reason for leaving:

Duties & responsibilities:


Employed from:

     /     /    

Employer name:

Supervisor name:

Starting salary:

Employed until:

     /     /    

Employer Address:

Supervisor Phone #:

Ending salary:

Job title:

Reason for leaving:

Duties & responsibilities:


General

Yes     No

May we contact your current employer for references?

Yes    No

If hired, will you be able to work overtime?

Yes    No

Will you be able to perform the essential job functions for the position you are applying for with or without reasonable accommodation?

Yes    No

Have you ever been convicted of a crime, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by court? (A yes response does not automatically disqualify your application.)

Certification & Authorization

The above information is true and correct.  I understand that, in the event of my employment by Choice Health Care, I shall be subject to dismissal if any information that I have given in this application is false or misleading, or if I have failed to give any information herein requested, regardless of the time elapsed after discovery.

I authorize Choice Health Care to inquire into my educational, professional, and past employment history references as needed to research my qualifications for this position.  I hereby give my consent to any former employer to provide employment related information about me to Choice Health Care and will hold the company and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information.  I further authorize Choice Health Care to obtain any credit and consumer checks.

I understand that nothing in this employment application, the granting of an interview, or my subsequent employment with Choice Health Care is intended to create an employment contract between myself and the company under which my employment could be terminated only for cause.  On the contrary I understand and agree that if hired, my employment will be terminable at will and may be terminated by me or Choice Health Care at any time and for any reason.  I understand that no person has any authority to enter into any agreement contrary to the foregoing.

If employed, I will be required to provide original documents which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of 1986.  The document(s) provided will be used for completion of Form I-9.

I hereby acknowledge that I have read and agree to the above statements.


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Signature                                                                             Date