2755 Bristol Street Suite 115, Costa Mesa, CA 92626
(949) 543-1300
info@specializedhh.com
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Complete
First Name
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Middle Name
Last Name
*
Email
*
Home Phone
*
Cell Phone
*
Home Address
*
Are you 18 or over?
*
Yes
No
Name Of Person Through Whom You May Be Contacted For Message Purposes
Phone
If hired, can you furnish proof that you are legally permitted to work in the U.S.
*
Yes
No
What Other Name Have You Been Employed Under If Different From Present Name?
Have you ever been convicted of a felony or misdemeanor?
*
Yes
No
If Yes, Please Explain
Names Of Relatives Employed Us?
Department
How Did You Learn About This Opening?
Have you ever been previously employed by this agency?
Yes
No
If Yes, When/Where?
Educational Record
High School
Location
Last Grade Completed?
9
10
11
12
Diploma
Yes
No
College 1
Location
Years Completed
1
2
3
4
Degree And Major
College 2
Location
Years Completed
1
2
4
Degree And Major
Other Education, Special Courses, Or Academic Honors
Colleges In Which You Are Currently Enroled
License/Certification 1
Type
Number
State Issued
Date Issued
Expires On
Confirmed
License/Certification 2
Type
Number
State Issued
Date Issued
Expires On
Confirmed
List Any Professional Organizations Of Which You Are A Member
U.S. Military Experience
Branch
Initial Rank
Final Rank
Service Schools Attended
Skills
Typing Speed
Shorthand Speed
10 Key Add. Mach. By Touch
Yes
No
PBX
Medical Terminology
Yes
No
List Other Knowledge Or Skills You Possess Or Equipment You Can Operate
Job Interest
First Choice
Second Choice
Date Available
Salary Desired
Hours & Shifts Available
Full Time
Part Time
On Call
Days
Evenings
Nights
Weekends
Employment History
Company
May We Contact?
Yes
No
Phone
Address
Average Hours Per Week
Worked?
Full Time
Part Time
Job Title
Immediate Supervisor
Employed From
Employed To
Nature of Duties
Starting Salary
Ending Salary
Reason For Leaving
Company 2
Company
May We Contact?
Yes
No
Phone
Address
Average Hours Per Week
Worked?
Full Time
Part Time
Job Title
Immediate Supervisor
Employed From
Employed To
Nature of Duties
Starting Salary
Ending Salary
Reason For Leaving
Company 3
Company
May We Contact?
Yes
No
Phone
Address
Average Hours Per Week
Worked?
Full Time
Part Time
Job Title
Immediate Supervisor
Employed From
Employed To
Nature of Duties
Starting Salary
Ending Salary
Reason For Leaving
Terms & Conditions
By pressing submit, I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and I agree to have any of the statements checked by the Agency unless I have indicated to the contrary. I authorized the references listed above to provide the Agency any and all information concerning my previous employment and any pertinent information that may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the Agency as well as from the use of disclosure of such information by the Agency or any of its agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, in my dismissal from employment. In consideration of my employment, I agree to conform to the rules and standards of the Agency and agree that my employment and compensation can be terminated, with or without cause, and with or without, at any time, either at my option or at the option of Agency. I understand that no employee or representative of the Agency other than the President of INTRACARE INC. has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Further, the President of INTRACARE INC. may not alter the at-will nature of the employment relationship unless he does so specifically and in writing. I also understand that all offers of employment are conditioned on the provision of satisfactory proof of an applicant’s identity and legal right to work in the U.S. I understand that any offer of employment with the Agency may be conditioned on completing a pre-employment medical examination. Purpose of medical examination is to determine whether I am able to perform the essential functions of the job I am offered with or without reasonable accommodation, to identify any reasonable accommodation if such is warranted, and to ensure that my performance of the essential functions does not present a direct threat to my health and safety or the health and safety of others. I agree to forego such pre-employment medical examination. If hired by the agency, I further agree to undergo any periodic medical examinations, which are permitted or required by Law. The Agency comply with Federal and State Laws which prohibit discrimination on the basis of race, color, age, sex religion, national origin, ancestry, disability or handicap. Veteran status, medical condition (as defined by California law), sexual orientation and material status.
Agreement
*
I agree to the terms of service