Are you 18 years of age or older?
Are you legally authorized to work in the United States?
Employment Position Desired:
Full time or Part time position desired:
Date you can start desired position:
Specify any days or times you are not available for work:
Are you currently employed?
If currently employed, may we contact your present employer?
Have you ever been employed by Grandvue?
If previously employed by Grandvue, when?
Do you have any relatives employed by Grandvue? If so, please provide names. This information will not affect hiring decisions but may be used to ensure appropriate reporting relationships.
How much time did you miss from work in the past year?
Have you ever been discharged by an employer or resigned in lieu of discharge?
If you have been discharged by an employer or resigned in lieu of discharge, explain all such incidents, giving facts, dates, describing any action you took and any resolution:
Employment History: List your previous employer. Be sure to include: Employers Name; Dates of Employment (Month and Year); Business Address; Phone Number; Your Title; Wages; Duties and Responsibilities; Reason for Leaving.
Employment History - List your second Previous Employer: Be sure to include: Employers Name; Dates of Employment (Month and Year); Business Address; Phone Number; Your Title; Wages; Duties and Responsibilities; Reason for Leaving.
Employment History - List your third Previous Employer: Be sure to include: Employers Name; Dates of Employment (Month and Year); Business Address; Phone Number; Your Title; Wages; Duties and Responsibilities; Reason for Leaving.
Employment History - List your fourth Previous Employer: Be sure to include: Employers Name; Dates of Employment (Month and Year); Business Address; Phone Number; Your Title; Wages; Duties and Responsibilities; Reason for Leaving.
Education - Highest Grade Completed:
Name of Last School Attended:
Vocational or Trade training:
Do you hold any licenses or certificates? If so, please list:
Have you ever had any license or certification placed under investigation, disciplinary action, suspended, revoked or put on probation? If you answered yes, explain in detail:
Have you ever been denied a license or certification? If you answered yes, explain in detail:
1st Reference: Please list the name of an individual, not related to you, whom you have known at least one year. Be sure to provide : Name; Address; Business; Years Acquainted; Phone Number.
2nd Reference: Please list the name of an individual, not related to you, whom you have known at least one year. Be sure to provide : Name; Address; Business; Years Acquainted; Phone Number.
3rd Reference: Please list the name of an individual, not related to you, whom you have known at least one year. Be sure to provide : Name; Address; Business; Years Acquainted; Phone Number.
Please provide an Emergency Contact. Be sure to include: Name; Relationship to you; Address; and Phone Number.
Verification: I understand that I may be required to submit to a physical examination, which may include a drug test, as part of the application process and that I must satisfactorily pass such an examination before I can start to work. I have read and fully understand the questions on this application for employment and have completely, truthfully, and accurately answered each question to the best of my knowledge. I understand that discovery of misrepresentation or omission of facts will be cause for immediate dismissal. I authorize and request licensing boards, references, educational institutions and my former employers, to provide Grandvue Medical Care Facility with any information requested pursuant to its investigation and employment decision. I also authorize and request federal, state and local governmental agencies to release to Grandvue Medical Care Facility any information concerning any criminal convictions on my record or medical information pertinent to my potential employment. I further understand and agree that if I am hired, unless I am covered by a union contract or other written agreement to the contrary, signed by me or on my behalf as a bargaining unit member, that my employment is at will and that it may be terminated, either by me or by Grandvue Medical Care Facility, at any time, with or without notice or cause. It is with this full understanding of Grandvue Medical Care Facility’s exclusive right to make such discharge decisions, that I will accept employment offered to me. (Please Sign and Date below):