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Resume (optional):

 
Please furnish some basic applicant information. If you wish to attach your resume, select the file to upload using the "Browse" button, complete the fields, and push the "Submit" button. Otherwise, simply complete the fields and push the "Submit" button. Fields marked with an asterisk are required.
 
APPLICANT DATA RECORD

First Name *
 

Middle Name

Last Name *
 

Address *
 

City *
 

State *

  

Zip *
 

Primary Phone *
 

Other Phone


Email Address


Position Applied For:

Date of App

Skill:

RN

LPN

PT

PTA

OT

OTA

ST

MSW

STNA

EMT

HHA

CNA

MA

Homemaker

Companion

Childcare Giver

Other:

Referral Source:

Career Builder

Newspaper

Internet Job Search

Yellow Pages

ANC Associate:

Other:

License/Certification No.

State

Exp. Date
 

License/Certification No.

State

Exp. Date
 

License/Certification No.

State

Exp. Date
 

State Approved Pharmacology Card?

State:
List Local Hospitals or Nursing Homes That You Have Worked for Either Directly or Through an Agency.
Indicate if You Would Be Willing to Accept Assignments to These Institutions.

1

3

2

4

SCHEDULING PREFERENCE (CHECK AREAS WILLING TO WORK)

Days

Evenings

Nights


7-3 Weekday

3-11 Weekday

11-7 Weekday


7-3 Weekend

3-11 Weekend

11-7 Weekend

No Hours Available Weekly: *

  

Status Desired: *

  

Placement:

Hospital

Nursing Home

Private Duty

Visits
SPECIAL SKILLS AND QUALIFICATIONS
Summarize Special Skills and Qualifications Acquired From Employment or Other Experiences Applicable to the Position.
EDUCATION
High SchoolBusiness/VocationalCollege/UniversityGraduate/Professional

School Name



Years Completed



Diploma/Degree



Did You Graduate?



Field of Study



GPA



PLEASE ANSWER THE FOLLOWING QUESTIONS

Have you ever been convicted of a felony? *

  

Have you ever filed an application here before? *

  

If yes, explain.

If yes, at what location and when?

Have you ever been convicted of a misdemeanor? *

  

Have you ever been employed here before? *

  

If yes, explain.

If yes, at what location and when?

A conviction includes, without limitation, pleading guilty, pleading no contest or having a finding of guilt. Employment will not be denied solely because of a conviction record, unless required by law.

Have you ever been employed at TriHealth (Bethesda and Good Samaritan of Cincinnati, OH)? *

  

If yes, at what location and when?

Are you prevented from lawfully becoming employed in this country because of Visa or immigration status? *

  

Are you employed now? *

  

(Proof of employment eligibility will be required upon employment.)

Have you ever been terminated from a job or asked to resign? *

  

If yes, explain.
IN CASE OF EMERGENCY, PLEASE NOTIFY:

Name: *

  

Address: *

  

Relationship:

Phone No: *

  
EMPLOYMENT HISTORY MUST REPRESENT LAST FIVE (5) EMPLOYERS OR FIVE (5) YEARS WHICHEVER IS GREATER.
START WITH MOST CURRENT JOB AND DOCUMENT ANY GAPS IN YOUR EMPLOYMENT HISTORY.
EMPLOYMENT HISTORY
1 

Dates Employed:

From:

To:

Rate of Pay:

Start:

End:

Employer:

Supervisor:

Phone:

Street:

City:

State:

Zip:

Job Title:

Work Performed:

Avg Hours/Week:

Reason for Leaving:
2 

Dates Employed:

From:

To:

Rate of Pay:

Start:

End:

Employer:

Supervisor:

Phone:

Street:

City:

State:

Zip:

Job Title:

Work Performed:

Avg Hours/Week:

Reason for Leaving:
3

Dates Employed:

From:

To:

Rate of Pay:

Start:

End:

Employer:

Supervisor:

Phone:

Street:

City:

State:

Zip:

Job Title:

Work Performed:

Avg Hours/Week:

Reason for Leaving:
4 

Dates Employed:

From:

To:

Rate of Pay:

Start:

End:

Employer:

Supervisor:

Phone:

Street:

City:

State:

Zip:

Job Title:

Work Performed:

Avg Hours/Week:

Reason for Leaving:
5

Dates Employed:

From:

To:

Rate of Pay:

Start:

End:

Employer:

Supervisor:

Phone:

Street:

City:

State:

Zip:

Job Title:

Work Performed:

Avg Hours/Week:

Reason for Leaving:
APPLICANT'S STATEMENT
I understand, if employed, any misleading or false information appearing on my application or given in an interview may result in dismissal. I understand I am required to abide by all rules and regulations of CHS. I have not knowingly withheld any information which would affect my consideration for employment. I authorize all persons, schools, companies, corporations, credit bureau and law enforcement agencies to supply information concerning my background. I release the aforementioned from all liability in providing any type of reference information. I understand neither this document nor any handbooks or written policies promulgated by CHS constitute a contract of employment. If employed, my employment with CHS is at will and my be terminated at any time, with or without cause, by CHS or me, unless a specific document to the contrary is executed by CHS executive management and me in writing. If offered a position, my employment may be contingent upon passing a skills test, a physical examination including a TB test (or x-ray if TB test is positive), a strength and agility test, a drug screening and satisfactory employment references. I understand I will not be excluded from employment on the basis of a physical examination unless the examination reveals a physical condition and prevents me from performing the essential functions of the job.

SSN#

Name_Signed

Date_Signed
Equal Opportunity Employer