EMPLOYMENT APPLICATION
APPLICATION
Position Applying for: ______
Personal Information
Name ______
Address ______City ______State _____ Zip Code ______
Phone Number where we can contact you or leave you a message ______
Social Security Number______Are you under 18 years of age? 1 Yes 1 No
Email Address ______
Other Pertinent Information
Have you ever been known by a different name? 1Yes 1 No If yes, what was it? ______
Are you legally eligible to work in the United States? 1 Yes 1 No
Have you ever been convicted of or pleaded guilty to a felony? 1 Yes 1 No
If yes, please explain ______
If licensed or certified, have you ever been disciplined by your credentialing/regulatory agency? 1 Yes 1 No
If yes, please explain ______
List names of friends or relatives employed by Gila Health Resources
Name Relationship City
______
______
How did you learn about our company?
______
Education
High School
Name of School ______
Location ______
Number of years attended: ______Did you graduate? 1 Yes 1 No
College / Vocational School
Name of School ______
Location: ______
Number of years attended: ______Did you graduate? 1 Yes 1 No
If yes, degree or diploma received: ______
College / Vocational School
Name of School: ______
Location: ______
Number of years attended: ______Did you graduate? 1 Yes 1 No
If yes, degree or diploma received: ______
Employment History
How many different employers have you worked for in the past five (5) years? ______
Please account for your employment history for the past five (5) years. Begin with your most recent or present place of employment first and work back in time. Please provide names and telephone numbers of supervisors.
Present or Last Employer
Company: ______
Address: ______
Name of Supervisor: ______Telephone Number: ______
Your Job Title: ______Dates Employed From: ______To: ______
Reason for Leaving: ______
Employer
Company: ______
Address: ______
Name of Supervisor: ______Telephone Number: ______
Your Job Title: ______Dates Employed From: ______To: ______
Reason for Leaving: ______
Employer
Company: ______
Address: ______
Name of Supervisor: ______Telephone Number: ______
Your Job Title: ______Dates Employed From: ______To: ______
Reason for Leaving: ______
Professional or Academic References – (No personal references, please)
Name: ______Entity Associated with: ______Telephone:______
Name: ______Entity Associated with: ______Telephone:______
If necessary, can GHR Management contact your employment or academic references in the next 48-hours?
1 Yes 1 No
If no, please provide a time frame: ______
Please Read the Following and Sign:
The information that I have provided Gila Health Resources in this application (and the accompanying resume or other pertinent documentation) is accurate and complete. I understand that any false or misleading information or omissions may disqualify me from further consideration for employment and may lead to my immediate discharge from employment if discovered at a later date. I agree to immediately notify Gila Health Resources if I should be convicted of a felony or any crime involving dishonesty, breach of trust, federally controlled substance, sexual misconduct, abuse or violence, while my application is pending or during my period of employment.
I understand that this application does not constitute a contract of employment. I understand that if hired, I am obligated to meet the terms of current and future Gila Health Resources policies.
______
Name (please print) Date
______
Signature
Human Resources
401 Burro Alley
PO Box 218
Morenci Arizona 85540
928.865.9184 phone
928.865.7571 fax
Gila Health Resources is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites employees to voluntarily self-identify their race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.
Your cooperation is appreciated. Please answer the following & check all that apply.
Voluntary Self Identification Form1 Position applying for / 2 How did you hear about this position?
1 1 Current Employee 1 2 Newspaper Ad
1 3 Internet 1 4 Recruiter 1 5 Other - Explain / 3 Today’s Date
4 Last Name / First Name / Middle Name
5. Gender
1 1 - Male 1 2 - Female
6. Ethnicity
1 1 - Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
1 2 - White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
1 3 - Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa.
1 4 - Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.
1 5 - Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
1 6 - American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment.
1 7 - Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above races.
7. Veteran Status
1 1 – Vietnam Era Veteran
1 2 – Special Disabled Veteran
1 3 – Other Eligible Veteran
Please return this form to: Gila Health Resources, PO Box 218, Morenci, AZ 85540