Full Name

Address

City, State, ZIP

Phone Number

Email Address

Are you legally authorized to work in the United States?

YesNo

If hired, can you provide proof of authorization?

YesNo

Employment Availability

Position Applied For

Desired Start Date

Employment Type

Full-TimePart-TimeTemporary

Days/Hours Available to Work

Education

High School

City/State

Did you graduate?

YesNo

College/Technical School

Degree/Certification

Employment History – Most Recent Employer

Company Name

Job Title

Dates of Employment

Supervisor Name/Contact

Reason for Leaving

Employment History – Previous Employer

Company Name

Job Title

Dates of Employment

Reason for Leaving

Criminal Background Disclosure

Have you ever been convicted of, pled guilty to, or pled no contest to a felony or misdemeanor (excluding minor traffic violations)?

YesNo

If yes, please explain (a conviction will not automatically disqualify you from employment):

References

Reference 1 – Name

Reference 1 – Phone

Reference 2 – Name

Reference 2 – Phone

HIPAA & Confidentiality Acknowledgment

I understand that if hired by First Choice Anderson Health & Wellness, I may have access to confidential patient information protected under HIPAA. I agree to maintain the confidentiality of all patient, employee, and company information during and after my employment. I understand that violation of confidentiality policies may result in disciplinary action, up to and including termination.

Applicant Certification

I certify that the information provided in this application is true and complete. I understand that false or misleading information may result in disqualification or termination. I authorize investigation of all statements and understand that employment is at-will and may be contingent upon successful completion of a background check and/or drug screening.

Upload Your Resume/CV (PDF/DOC)

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