DIVINE HEALTHCARE
APPLICATION FOR EMPLOYMENT
· All information obtained within this application will be held in strict confidence, subject to applicable law.
· Please complete all applicable sections and sign the last page.
· Please print clearly.
· Travel may be required for certain positions and valid driver’s license/insurance may be required upon hire.
Divine Healthcare prides itself on being an Equal Opportunity Employer. We will not discriminate in employment because of sex, age, race, physical disability, religion, ethnicity, mental disability, marital status, ancestry, or place of origin.
Date: ______________________
Name: _________________________________________Telephone :( )__________
Social Security Number ___________________
Address________________________________________________________________
__________________________________________Postal Code___________________
Are you legally entitled to work in the USA? _________________________________
Are you 18 years of older? (For child labor law purpose only)___________________
Position(s) applied for:____________________________________________________
Days that you can’t or won’t work? I.e. religious reasons, etc.___________________
Date you are available for employment:_____________Wage or salary desired?____
Have you ever worked for Divine healthcare before?_____If yes, when and where?_
EDUCATIONAL BACKGROUD & MILITARY EXPERIENCE
Divine healthcare has a company policy of stating a minimum educational level of Grade 12 or equivalent for all positions.
EDUCATIONAL BACKGROUND-relevant to the position applied for___________
Highest level of education completed:________________________________________
Name of educational institution:____________________________________________
What machines or equipment have you operated that relates to the position you have
applied for?____________________________________________________________
Employer’s name________________________________________________________
Commencement date:_______________________Departure date:________________
Reason for departure:_____________________________________________________
Supervisor’s name:______________________________Telephone( )_____________
Position(s) held:__________________________________________________________
Duties:_________________________________________________________________
May we contact this employer?(If not, state brief reason):______________________
Are there any skills, experience, and other qualifications that you feel would assist you in performing the duties of the position you have applied for?________________
Do you have any military experience?(If yes, please include branch and highest rank)__________________________________________________________were you
dishonorably discharged?(If yes, please explain)_______________________________
LIST BELOW YOUR LAST THREE EMPLOYERS, STARTING WITH THE MOST RECENT.
Employer’s name_______________________________________________________________
Commencement date:______________________Departure date________________________
Reason for departure:___________________________________________________________
Supervisor’s name_____________________________Telephone( )____________________
Position(s) Held:________________________________________________________________
Duties:________________________________________________________________________
May we contact this employer?(If not, state brief reason):______________________________
Employer’s name:______________________________________________________________
Commencement date:_______________________Departure date______________________
Reason for departure:___________________________________________________________
Supervisor’s name:___________________________Telephone :( )______________________
Position(s) held:________________________________________________________________
Duties:________________________________________________________________________
May we contact this employer? (If not, state brief reason)_____________________________
Employer’s name:______________________________________________________________
Commencement date:___________________Departure date___________________________
Reason for departure:___________________________________________________________
Supervisor’s name:_______________________________Telephone: ( )_________________
Position(s) held_________________________________________________________________
Duties:________________________________________________________________________
May we contact this employer? (If not, state brief reason)_____________________________
______________________________________________________________________________
IF YOU ARE APPLYING FOR A POSITION THAT REQUIRES DRIVING, PLEASE COMPLETE THIS SECTION:
Do you have a valid driver’s license?_____License#________________State________
Note: If you are selected for an interview, you are required to present a copy of your driving record that is not more than 4 weeks old. After being hired, a copy of this driving record will be placed into your personnel file and an annual update will be required.
False information given or implied on an application for employment will be grounds for immediate dismissal without further notice.
I hereby state that all information provided is accurate and may be verified by Divine Healthcare. I agree that I may be discharged if Divine Healthcare at any time learns of falsification or material omission in the information provided on this application form and related documents. Divine Healthcare may contact my former employer(s) in connection with the consideration of my employment with them. I hereby release Divine Healthcare, its affiliates, successors, and assignee, and all references from any liability that might be claimed because of information provided by such references.
I agree that I will follow all company policies, procedures, and other directions pertaining to my employment. I understand that Divine Healthcare reserve the right to add, change, and/or delete any policies, procedures, work rules, and benefit at any time.
Applicant signature: ____________________________________Date:_____________
NO CONSIDERATION OF EMPLOYMENT WILL BE GIVEN TO ANY APPLICANT WHO DOES NOT SIGN THE ABOVE STATEMENT.
Thanks for showing an interest in pursuing a career with Divine Healthcare.
