You are applying for the following position: Job title

The job is located at: Job location

Date of application: Date prefilled

Applicant Instructions:

Thank you for your interest in working at our company. We appreciate your application and look forward to the possibility of you joining our team.

Please print all information (in ink) so it may be easily read. You may include attachments, such as a resume, letters of recommendation or past evaluations, however the application must still be completed.

Be certain all pages are completely filled out and signed. Use the abbreviation “N/A” if a particular provision or section in the form is not applicable to you. Incomplete applications will not be considered.

Please note the following:

Your application will remain in our active files for a period of six (6) months. Should an opening occur for a position indicated on your application, your application will be reviewed along with others. If you are among the most qualified applicants for a position, an interview will be arranged. Please notify us if your address or telephone number changes.

Employment decisions are made solely on the basis of qualifications to perform the work for which you are applying. Qualifications include education, training, work experience and other factors which are relevant in determining job performance. Credentials and experience will be verified through schools, former employers and licensing / certification agencies, if applicable. As an Equal Opportunity Employer, decisions to hire and promote are made without regard to race, color, creed, national origin, sex, physical and mental disability (unrelated to ability to do the job), or age (as defined by law).

We appreciate your cooperation.
If you are applying for a Certified Home Health Aide or Personal Care Assistant, an additional State Application will be required to be completed on-site.
Name:  
Social Security Number:  
Present Address:
Address 1:  
Address 2:  
City: State: Zip:
Permanent Address: same as present address
Address 1:  
Address 2:  
City: State: Zip:
Phone Number: ( ) -  
Cell Number: ( ) -  
Email:
Are you 18 years of age, or over?
Are you authorized to work in the United States and after employment, can you provide proof of employment eligibility?
Have you ever been convicted of a felony, misdemeanor or received deferred adjudication?
If yes, please explain
Have you ever been discharged from employment?
If yes, please explain
Employment Desired:
You are applying for the following position: Job title
Second Preference:
Date Available to Start Work:
Salary Desired:  
Please indicate which status and shift you are willing to work:
Full Time: Part-Time: Temporary: PNR: Per Visit : Full Time:
Independent Contractor:
Are you currently employed?
May we contact your current employer?
If no, please explain
Have you ever applied with us before?
Date applied: Not Applicable
Have you ever been employed by Indian Territory Home Health & Hospice, Indian Territory Provider Plus, Indian Territory DME or Family Medical Clinic this company?
Date Last Employed with Indian Territories:
Not Applicable
Position:
Last name under which you worked:
Reason for leaving:
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