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| Address | |
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| Telephone Number | |
| Social Security Number |
Are you over 18 years old? Yes No
Are you authorized to work in the U.S. on an unrestricted basis? Yes No
Can you perform the essential functions of the job for which you are applying with or without reasonable accommodation? Yes No
How did you learn of this opening?
Have you ever worked for Health Services, Inc. before? Yes No
When?
Do you have any relatives currently working for Health Services, Inc? Yes No
If so, name and relationship
Have you ever been convicted of a felony? (Conviction will not necessarily disqualify an applicant for employment) Yes No
If yes, describe conditions:
U.S. Service Record
Veteran of U.S. Armed Forces? Yes No
If so, which branch?
Rank at discharge
Dates of Service
Reason for discharge
National Guard member? Yes No
Position applied for:
Part-Time Full-Time
Salary Desired
Date available for work
| Education | Name and location of school | Year graduated | Major | Degree Received |
| High school | ||||
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| Other |
Do you plan to continue school at any time in the near future? Yes No
If so, when?
What major?
Do you speak, write, or understand any foreign languages? Yes No
If so, which language(s)
Professional licenses or certifications
| Type | State/Date Issued | Expiration | License Number |
Computer Skills
List programs you are proficient in and how long you used them:
Other Skills
List any other relevant skills you may have that would be beneficial to this position:
Work-related References
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Work History (If none, please put none in the first block)
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Applicant's Certification and Agreement
PLEASE READ AND CHECK BELOW (If there is any part of this statement you do not understand, please ask about it before agreeing to this statement.)
I certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any documents used to secure employment will be grounds for rejection of this application, or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
I hereby authorize Health Services, Inc. to thoroughly investigate my references, work records, education and other matters related to my suitability for employment and further, authorize my current and former employers to disclose to Health Services, Inc. any and all letters, reports and other information pertaining to my employment with them, without giving me prior notice of such disclosure. In addition, I hereby release Health Services, Inc. my current and former employers, and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. I further understand that Health Services, Inc. is a drug-free environment and that any job offer is contingent upon successful completion of a pre-employment drug screen.
I understand that nothing contained in the application or conveyed to me during any interview, which may be granted is intended to create an employment contract, implied or explicit, between me and Health Services, Inc. In addition, I understand and agree that if I am employed, my employment relationship with Health Services, Inc is strictly voluntary and at our mutual will. I understand that if employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, with or without cause or reason, at the option of either myself or Health Services, Inc. and that no promises or representations contrary to the forgoing are binding on Health Services, Inc. unless made in writing and signed jointly by the CEO and myself.
Furthermore, if employed, I agree that any dispute arising out of the termination of our employment relationship shall be resolved pursuant to Health Services, Inc. personnel policies and procedures.
I understand and agree that any future changes in my title, duties, compensation, working conditions and/or Health Services, Inc. benefits, policies and procedures will not alter our at-will agreements.
I understand that if offered employment, I will, as a condition of employment, be required to submit proof of my identity and legal right to work in the United States on my first day of employment.
If the position applied for requires driving in the course of work, I understand that I will be required to possess a current and valid Alabama driver's license. I also understand that any offer of employment is contingent on my ability to be covered by Health Services, Inc. auto insurance, if required for my position.
I agree with the above statement.
Pre-Employment Drug Screening Agreement
I hereby consent to submit to a urinalysis and/or other tests as shall be determined by Health Services, Inc. in the selection process of applicants for employment for the purpose of determining substance use.
I further understand and agree that this drug screen will be utilized in the selection process of applicants for employment for the purpose of determining substance use. I understand that Health Services, Inc. may request additional drug screens pursuant to the Drug-Free Workplace ace of 1988 are separate and independent to this Pre-employment Drug Screen Agreement.
I agree that Southeastern Industrial Medicine may collect these specimens for the tests required for analysis.
I further agree to, and hereby authorize, the release of the results of said tests to Health Services, Inc. designated Medical Review Officer (Dr. Michael Turner), and from Dr. Turner to the employer.
I further agree to hold harmless this company and its agents and Dr. Michael turner's office from any liability arising in whole or in part from the collection of specimens, testing, and use of the results from said tests in connection with the company's consideration of my application for employment.
I further agree that a reproduced copy of this pre-employment consent and release form shall have the same force and effect as the original.
I have carefully read the foregoing and fully understand its contents. I, as an individual seeking employment with Health Services, Inc., agree that I have a choice and I choose to consent to the invasion of my privacy resulting from the testing. I understand that I have the right to decline to take the Pre-Employment Drug Screen but I choose to take the drug screen without duress and under my own free will.
I do not agree with the above statement.
I agree with the above statement.
Criminal Background Check Authorization
I hereby authorize Health Services, Inc., and /or its agents to investigate my background to determine any and all information of concern to my record, whether same is of record or not. I authorize the release of this information by the appropriate agencies/investigating service to Health Services, Inc. I understand that this background investigation may include the checking of sources such as, but not limited to: federal, state and county criminal history records, social security number and address verification, and any professional licensing authorities.
I hereby release this company, its affiliates, its employees and its authorized agents from any liability in connection with any information they give or gather and any decisions made concerning my employment based on such information. I understand that any offer of employment I may receive is contingent upon the successful completion of the background investigation, but that the existence of a prior criminal record will not necessarily make me ineligible for employment. It is the policy of Health Services, Inc. to evaluate any adverse information obtained based on the time, nature and job-relatedness of the offense. The information on this form, along with the final report, will be held in confidence.
I further understand that I have the right to request a disclosure of the nature and scope of this investigation by providing Health Services, Inc. a written request within 60 days of the background investigation.
I do not agree with the above statement.
I agree with the above statement.