Employment Application

Applicants Certification and Agreement
Please Read Carefully

I verify that all the information which I have provided on this application and in any resumes and exhibits are true, correct, and complete. I understand that any false, misleading, incomplete, or omitted information will result in rejection of my application or dismissal from employment, whenever discovered. If my application is considered for employment, I authorize AHCP to conduct an investigation of my suitability for employment and to obtain verification of information that I provided on this application, resumes, and exhibits. I authorize such information to be used for any decisions related to my hiring and continued employment. AHCP will conduct a background and reference check on candidates offered positions of employment.

I understand that this application is not a job offer. If hired, I understand that the first one eighty (180) days of employment at AHCP will be considered as a period of adaptation and employment may be terminated during this period by either the employee and/or the employer with no eligibility for benefits or termination pay. My employment is not for a stated period of time and I may resign or be terminated with or without cause at any time, at the option of either myself or AHCP. I understand that I may be working in one or all subsidiaries of AHCP and that my shift or schedule may vary.

Employment is subject to completion of pre-employment procedures, including but not limited to, verifying employment and personal references, as appropriate criminal background check and driving record, and verification of licensure, certification, or registration. In addition, if hired, applicants must complete a Federal I-9 form and provide verifiable documentation of their legal right to reside and work in the United States. I also understand that offer of employment is contingent upon passing a pre-placement physical exam and health screening and may require a drug testing. If employed, I will comply with all policies, procedures, and work rules. In the event that I am photographed or interviewed during the course of my employment, AHCP has my permission to use any and all materials gathered.

Name(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone(Required)

Work Phone(Required)

May we contact you at work?(Required)

Yes

Best time to reach you

Have you ever been employed, licensed, certified, or received a degree under a different name?

Are you related to any employees of American Health Care Professionals?

Are you a citizen or otherwise legally able to work in the U.S.? (Proof ocitizenship/ immigration status will be required upon employment).

If Yes, please indicate name and relationship

Have you ever applied or worked at this organization before?

If Yes, position you held

Reason for leaving

How did you learn of American Health Care Professionals?

Have you ever pled guilty to, been convicted of, or are presently charged with any violation of the law, other than a traffic or speeding violation?

If Yes, please explain. (Answering Yes Does Not Automatically Disqualify You For Consideration For Employment).

Are you currently serving probation, conditional discharge or pretrial diversion for any crime?

If Yes, provide details on offense, disposition and current status

Position for which you are applying

Date available for employment?

SalaryDesired?

Employment Desired?

Preferred Shift

High/Prep School (Name and Address)

College (Name and Address)

Date of Graduation

Degree/Major

Please indicate all other training that may be relevant to your application

List any additional qualifications or skills you have for the position for which you have applied

List any languages in addition to English you can speak

List any languages in addition to English you can write

List any languages in addition to English you can read

Describe your computer skills

If required, do you hold a valid license/certification/registration for the position for which you have applied?

If yes, please state license /certification /registration number

Expiration date

Have you ever been denied a professional or occupational license, certification or registration?

If yes, provide detailed explanation

Has any license, certification or registration that you hold/held ever been investigated, revoked, suspended, limited or subject to discipline by any board or governing authority?

If yes, provide issuing state(s), type of license/certification/registration and numbers and please explain in detail

Have you ever been denied professional liability insurance or had such a policy cancelled?

Do you hold a valid driver's license?

Do you have an automobile insurance policy in effect? (A certificate of insurance naming American Health Care Professionals as a certificate holder is required at the time of employment)

Employer (Current or most recent employer)

May we contact?

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Salary

Dates employed there

Position Held

Reason for leaving

Name of Supervisor

Personal Reference #1

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Relationship

Years known

Personal Reference #2

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Relationship

Years known

Please read agree to our Privacy Policy(Required)

I have read and understand the Privacy Policy

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