Employment Application

Applicant Information

Education

Previous Experience

References

Disclaimers

Step 1
Applicant Information
- First Name*
- Middle Name
- Last Name*
- Any Previous Names (including Maiden name)
- Current Address*
- Apartment/Unit
- City*
- State*
- Zip*
- Phone Number*
- Email*
- Job Applied For: *
- Annual Salary Desired*
- Are you applying for full-time or part time? *
  Full Time Part Time
  Are you applying for full-time or part time? is required
- Would you consider working:
  
  I would consider working: Weekends & Holidays *
  Yes No
  Whether you will work Weekends & Holidays is required
  
  I would consider working: On Call *
  Yes No
  Whether you will work On Call is required
  
  I would consider working: 1st Shift *
  Yes No
  Whether you will work 1st Shift is required
  
  I would consider working: 2nd Shift *
  Yes No
  Whether you will work 2nd Shift is required
  
  I would consider working: 3rd Shift *
  Yes No
  Whether you will work 3rd Shift is required
  
  I would consider working: Rotating Shift
  Yes No
- Have you ever worked for this facility?
  Yes No
  Whether you have prior employment with this facility is required
  If yes, When?
- Do you have friends or relatives that work for this facility? *
  Yes No
  Whether you have friends or relatives who work for this facility is required
  
  Friend/Relative Name
  
  Department
  
  Relationship
- Are you 18 years of age or older?*
  Yes No
  Whether you are 18 years of age or older is required
- Are you a US Citizen or Alien legally authorized to work in the United States?*
  Yes No
  Whether you are a US Citizen or Alien legally authorized to work in the United States is required
- Long Range Occupational Goals
Step 2
Education/Skills and Professional Licenses
High School
- High School Name*
- Address*
- Last Year Completed*
  1 2 3 4
  Last Year Completed is required
- Did You Graduate?*
  Yes No
  Whether you graduated is required
- List Diploma or Degree*
College
- College Name
- Address
- Last Year Completed
  1 2 3 4
  Last Year Completed is required
- Did You Graduate?
  Yes No
  Whether you graduated is required
- List Diploma or Degree
Other Business College or Special Courses
- Special Military Training, Post Graduate and Nursing
- Area(s) of specialization or major interest
- List office skills including computer/software experience
- Word Processing (Approx. WPM)
Professional Licenses
- Professional License or Registration
  Currently Licensed Currently Registered Eligible for License Eligible for Registration
- Professional License or registration ever suspended, revoked, or on probation?
  Yes No
- Type
- State
- Number
- Date
- Professional Certifications
  Currently Certified Eligible for Certification
- Type
- State
- Date
Step 3
Previous Experience
Previous Job #1
- Job Title*
- Employed From*
- To*
- Supervisor Name *
- Company Name*
- Address
- City
- State
- Zip
- Duties *
- Reason for Leaving*
- Do you have another previous employment?*
  Yes No
  Whether you have another previous employment is required
Previous Job #2
- Job Title*
- Employed From*
- To*
- Supervisor Name *
- Company Name*
- Address
- City
- State
- Zip
- Duties *
- Reason for Leaving*
- Do you have another previous employment?*
  Yes No
  Whether you have another previous employment is required
Previous Job #3
- Job Title*
- Employed From*
- To*
- Supervisor Name *
- Company Name*
- Address
- City
- State
- Zip
- Duties *
- Reason for Leaving*
- Do you have another previous employment?*
  Yes No
  Whether you have another previous employment is required
Previous Job #4
- Job Title*
- Employed From*
- To*
- Supervisor Name *
- Company Name*
- Address
- City
- State
- Zip
- Duties *
- Reason for Leaving*
Please identify and explain any gaps in employment longer than three (3) months

Upload Resume

Accepted formats: .pages, .doc, .docx, .pdf, .png, .jpg

Select files from your computer
or simply drag & drop them here

Language Skills

Do not complete unless requested.
- Language
- Do you speak?
  Fair Good Fluent
- Do you read?
  Fair Good Fluent
- Do you write?
  Fair Good Fluent
Step 4
References

List references who are not relatives
Reference 1
- Full Name*
- Relationship *
- Title *
- Phone Number*
- Email*
- Company Name
- Company Address
- City
- State
- Zip
Reference 2
- Full Name*
- Relationship *
- Title *
- Phone Number*
- Email*
- Company Name
- Company Address
- City
- State
- Zip
Reference 3
- Full Name*
- Relationship *
- Title *
- Phone Number*
- Email*
- Company Name
- Company Address
- City
- State
- Zip
Step 5
Carefully read this section prior to hitting submit.

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete.

I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date. I understand that I will be required to satisfactorily complete a drug, alcohol and tobacco use screening as a condition of employment.

Graham Health System is committed to providing a safe and healthy work environment and to promote the health and well-being of their employees.
- Provision of Information
  I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information. *
  Authorizing provision of information is required.
- Employment At Will
  I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized. *
  Understanding the nature of the employment is required.
- Agree to Terms
  I hereby acknowledge that I have read the above statements, understand them and agree with them. *
  Your agreement to the above statements is required.

Applicant Information

Education/Skills and Professional Licenses

High School

College

Other Business College or Special Courses

Professional Licenses

Previous Experience

Previous Job #1

Previous Job #2

Previous Job #3

Previous Job #4

Upload Resume

Language Skills

References

Reference 1

Reference 2

Reference 3

Carefully read this section prior to hitting submit.