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Employment

Position Applied For: at
First Name: Last Name:
Address:
City: State:
Zip: Phone:
Email:
Salary Range Desired:
 
Attach Resume:
Acceptable formats: .doc, .wpd, .txt, .wks, .pdf
Are you at least 18 years of age? Yes No
Do you have the legal right to work in the US? Yes No
Have you ever been convicted of a felony? Yes No
If yes, please explain:
I am available (check all that apply):
Full Time
Part Time
 AM Shift
PM Shift
Have you ever served in the military? Yes No
If yes, branch of service: discharge Date: Pick Date
How were you referred?
Employee referral
Newspaper ad
Other- explain
 Walk-in
Company vehicle
Referral explanation:
Have you ever applied to or been employed by Northwest Respiratory Services? Yes No
 
Employment History
Please list chronologically, beginning with most recent experience.
Employer: City/State:
From (MM/YYYY): Pick Date
 To (MM/YYYY): Pick Date
Supervisor: Phone:
Salary:
Position Title:
Type of Work/Duties:
Reason for Leaving:
May we contact this employer?: Yes No
 
Employer: City/State:
From (MM/YYYY): Pick Date
 To (MM/YYYY): Pick Date
Supervisor: Phone:
Salary:
Position Title:
Type of Work/Duties:
Reason for Leaving:
May we contact this employer?: Yes No
 
Employer: City/State:
From (MM/YYYY): Pick Date
 To (MM/YYYY): Pick Date
Supervisor: Phone:
Salary:
Position Title:
Type of Work/Duties:
Reason for Leaving:
May we contact this employer?: Yes No
 
Education
Name & Location of School Did you graduate? Major/Coursework Diploma/Degree
High School
College/University
College/University
Business or Trade School
 
Drivers License
If Position Requires Driving this section must be completed. (e.g. Branch Manager, Service Technician)
Do you have a driver's license?: Yes No
If so, what class of license?: A B C D
Years of driving experience?:
Have you ever had your driver's license suspended or revoked?: Yes No
If yes, please explain:
Driver applicants may be required to furnish a current copy of their Motor Vehicle Record, obtainable from the Driver’s License Division of the Secretary of State. An unsatisfactory record will automatically disqualify an applicant for this type of position only.
Do you understand this qualification?: Yes No
  
I understand that the employer follows an employment-at-will policy, in that if I am hired, I or the employer may terminate my employment at any time, or for any reason consistent with applicable state or federal law. I understand that this application is not a contract of employment. I understand that to be employed I must be lawfully authorized to work in the United States, and I must have documentation to support my eligibility.

I understand that the company may thoroughly investigate my work and personal history and verify all data given on this application, on related papers, and in interviews. I authorize all individuals, schools, and firms named herein, except my current employer if so noted, to provide any information requested about me, and I release them from all liability for damage in providing such truthful information.

I certify that all above statements herein are true and understand that any falsification or willful omission given in my application or interview(s) shall be sufficient cause for dismissal or refusal of employment.

Check this box to certify that you have read and accept the above statement.
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