Job Application

Date of Application

*First Name

Middle Name

*Last Name

Maiden Name

*Street Address

*City

*State/Zip

*Telephone Number(s)

*Email

If you have resided at your present address less than three years, list your prior address:

Street Address

City

State/Zip

Position(s) Desired:

RN/Nurse Practitioner/Physician’s Assistant

Upload Resume /
Cover Letter:

*File must be in .doc, .docx or .pdf format.

Current Salary

Salary/Wage Expected

Are you available to work:

Full-Time Part-Time Temporary

On what date would you be available for work? (mm/dd/yyyy)

Schedule (Days Available)

Are you on a layoff and subject to recall at another employer?

Yes No

Have you ever filed an application with us before?

Yes No

If yes, give date (mm/dd/yyyy)

Have you ever been employed with us before?

Yes No

If yes, give date (mm/dd/yyyy)

Do you have any relatives that are employed here?

Yes No

If yes, please list them here.

Why do you think you would make a valuable employee to our company?

Are you lawfully entitled to be employed in the United States?
(Proof of citizenship or immigration status will be required upon employment.)

Yes No

Are you 18 years or older?

Yes No

Have you been convicted of any crime?
(Conviction will not necessarily disqualify an applicant from employment.)

Yes No

If yes, please explain:

Emergency Contact Name

Emergency Contact Address

Emergency Contact Phone

EDUCATION

High School
Name & Location

Course of Study

No. of Years Completed

Did You Graduate?

Yes No

Degree or Diploma

Business/Trade/Technical
Name & Location

Course of Study

No. of Years Completed

Did You Graduate?

Yes No

Degree or Diploma

College
Name & Location

Course of Study

No. of Years Completed

Did You Graduate?

Yes No

Degree or Diploma

Graduate School
Name & Location

Course of Study

No. of Years Completed

id You Graduate?

Yes No

Degree or Diploma

List special job related skills?

List specific job related skills?

REFERENCES:

1. Name:

Phone Number:

Address:

2. Name:

Phone Number:

Address:

3. Name:

Phone Number:

Address:

EMPLOYMENT

Please give accurate complete full-time and part-time employment record. Start with your present or most recent employer. Please document reasons for employment gaps.

Note: We may contact the employers listed above or on your resume unless you indicate those you do not want us to contact.

1. Company Name

Telephone

Address

Employed (mm/dd/yyyy)

From To

Name of Supervisor

Salary

Salary Hint: Please use numbers only. Do not use commas or the dollar sign. EX: 22000

Start $ Last $

State Job Title & Describe Your Work

Reason For Leaving

DO NOT CONTACT

Reason

2. Company Name

Telephone

Address

Employed (mm/dd/yyyy)

From To

Name of Supervisor

Salary

Salary Hint: Please use numbers only. Do not use commas or the dollar sign. EX: 22000

Start $ Last $

State Job Title & Describe Your Work

Reason For Leaving

DO NOT CONTACT

Reason

3. Company Name

Telephone

Address

Employed (mm/dd/yyyy)

From To

Name of Supervisor

Salary

Salary Hint: Please use numbers only. Do not use commas or the dollar sign. EX: 22000

Start $ Last $

State Job Title & Describe Your Work

Reason For Leaving

DO NOT CONTACT

Reason

4. Company Name

Telephone

Address

Employed (mm/dd/yyyy)

From To

Name of Supervisor

Salary

Salary Hint: Please use numbers only. Do not use commas or the dollar sign. EX: 22000

Start $ Last $

State Job Title & Describe Your Work

Reason For Leaving

DO NOT CONTACT

Reason

Have you ever been discharged from any position?

Yes No

If yes, please explain.

* You must initial all the boxes below in order to submit your application.

I certify that this application was completed by me and that all entries and information in it are TRUE and COMPLETE to the best of my knowledge. I understand that false, misleading or omitted information in my application may result in its rejection, the revocation of an offer of employment, or discharge.

I authorize investigation of all statements contained in this application as may be necessary in arriving at an employment decision. I understand that an investigation may be made and information me be obtained through Interviews with personal references and past employers, through a credit check, a criminal history check and/or a driver's record check. This inquiry may include information as to, among other things, my character, general reputation and personal characteristics, as well as information about my work performance and workplace conduct. I consent to this investigation and to the consideration of any statements of references, former employers or others that are given in response to the inquiry. If Woodlands Behavioral Health Network decides to obtain a consumer credit report, I understand that Woodlands Behavioral Health Network, will provide, at my request, the name and address of the reporting agency so I may obtain from such reporting agency the nature and substance of information contained in such report.

I hereby release all parties, including but not limited to Woodlands Behavioral Health Network personal references and previous employers, from liability for an injury or damage that may result from their furnishing information concerning me or any action Woodlands Behavioral Health Network takes on the basis of such information.

I understand that, if I am offered a job, as a condition of beginning my employment, I may be required to undergo a drug screen, and I hereby authorize any doctor, hospital, clinic, laboratory and/or other medical facility to furnish any medical information with reference to me as may be necessary in conjunction with that examination and related considerations.

I understand that, according to federal law, all individuals who are hired must, as a condition of employment, produce certain documentation to verify their identity and United States citizen status or, ir aliens, their legal authorization to work in the United States. As a consequence, I understand that any offer of employment to me is contingent upon my ability to produce the required documentation within the time period required by law.

I understand that this application is not, and is not intended to be, a contract of employment and that any resulting employment is for no fixed period of time and is terminable at any time and for any reason by me or by Woodlands Behavioral Health Network I further understand that statements which may be contained in policies, practices, handbooks or other material do not create any guarantee of employment and that Woodlands Behavioral Health Network has the right to modify, amend or terminate policies, practices, benefits plans or other programs within the limits and requirements imposed by law.

I certify that I am not bound by any employment contract or non-competition agreement that would be breached by any employment that might be offered to me by Woodlands Behavioral Health Network, nor am I in possession of nor will I at any time reveal to Woodlands Behavioral Health Network, under any circumstances, and proprietary or confidential information that is subject of any contract, non-disclosure agreement or prior work relationship involving any other person or entity.

Confirmation

By checking this box, I understand that Woodlands Behavioral Health Network agrees to use the information from the appropriate law enforcement agencies to verify information on my application for employment, statements I have made in regard to my employment, and for any determination into my good moral character.

I understand that acceptance of an offer of employment does not create contractual obligation to continue to employ me in the future.

In the event of employment, I understand that false or misleading information given in my application, resume or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

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