EMPLOYMENT APPLICATION

Application Email To:  jobs@outreachhealth.com
Your Email Address:    *
Position Applied for:  *
Date of Application:  4/18/2014
How did you find out about this position?
 

CONTACT & PERSONAL INFORMATION

*First Name: *Last Name: Middle:
*Current Address:
*City: *State: *Zip:
Permanent  Address:
City: State: Zip:
*Social Security Number:         *Driver Licence Number
Phone numbers: *(Day) (Evening)  (Wknd)
Are you 18 years of age or older? Yes  No
Have you been convicted of a felony crime? Yes  No     If yes, please explain:
I understand that as an applicant, I will be subject to state laws which mandate that persons convicted of certain crimes may not be employed by OHS.
Are you legally authorized to work in the United States? Yes  No    (Proof of citizenship or legal authorization will be required upon emploment.)
 

EMPLOYMENT AVAILABILITY

Please indicate the hours you are available to work:        Full Time  Part-Time
 

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

AM

PM

Comments:
Date Available to Begin Work: 
Are you willing to work evenings or weekends? Yes  No     If yes, when:
 

EDUCATIONAL HISTORY

Name of School

Course of Study

Did you Graduate?

Diploma or Degree

High School   

College(s)  

                  

Graduate School(s)

Other (Specify) 

Plans for Future Education
 

PROFESSIONAL LICENSES, CERTIFICATES, REGISTRATIONS

Type of License, Certification or Registration

Issued By

Registration or Certification No.

Date Issued

Expiration Date

Has License, Certification or Registration ever been suspended, restricted, or revoked?    Yes  No
If yes, explain:
 

SPECIAL SKILLS/LANGUAGES

List any special skills you possess and/or equipment or office machines you can operate.
Telephone System:      10-Key Calculator:
Data Entry: 
Typing Speed: 10-30 words per minute (wpm)  30-50 wpm More than 50 wpm
Software & Computer Skills:
Other Skills:
Languages (other than English):
1.           Speak  Read Write
2.         Speak  Read Write
3.         Speak  Read Write
 

EMPLOYMENT RECORD

Have you ever worked for Outreach Health Services before?    Yes, Date:             No
We routinely contact an applicant's current employer for reference checks. Would this pose any difficulty for you? Yes  No
If yes, please explain:
 
 

PLEASE ACCOUNT FOR LAST 10 YEARS OF EMPLOYMENT, BEGINNING WITH CURRENT OR LAST EMPLOYER. ENTRIES 2-5 SHOULDBE ENTERED ON THE FOLLOWING PAGE, AND ADDITIONAL PAGES MAY BE USED AS NECESSARY.

 
CURRENT OR LAST EMPLOYER:      Type of Business:
Address:   City:   State:   Zip:
Job Title:      Brief Description of Job:
Start Date:  End Date:  Start Salary:  End Salary:
Reported to:  Title:  Telephone:
May we contact this person? Yes  No     Reason for seeking change:
 

EMPLOYMENT RECORD (CONTINUED)

Previous Employer:     Type of Business:
Address:   City:   State:   Zip:
Job Title:      Brief Description of Job:
Start Date:  End Date:  Start Salary:  End Salary:
Reported to:  Title:  Telephone:
May we contact this person? Yes  No     Reason for seeking change:
 

EMPLOYMENT RECORD (CONTINUED)

Previous Employer:     Type of Business:
Address:   City:   State:   Zip:
Job Title:      Brief Description of Job:
Start Date:  End Date:  Start Salary:  End Salary:
Reported to:  Title:  Telephone:
May we contact this person? Yes  No     Reason for seeking change:
 

EMPLOYMENT RECORD (CONTINUED)

Previous Employer:     Type of Business:
Address:   City:   State:   Zip:
Job Title:      Brief Description of Job:
Start Date:  End Date:  Start Salary:  End Salary:
Reported to:  Title:  Telephone:
May we contact this person? Yes  No     Reason for seeking change:
 

EMPLOYMENT RECORD (CONTINUED)

Previous Employer:     Type of Business:
Address:   City:   State:   Zip:
Job Title:      Brief Description of Job:
Start Date:  End Date:  Start Salary:  End Salary:
Reported to:  Title:  Telephone:
May we contact this person? Yes  No     Reason for seeking change:
 

REFERENCES

Name

Relationship

Phone Number

1      

2      

3      

I authorize the references listed above to give you all information concerning my employment with them, and pertinent information they may have, personal or otherwise. Further, I release all parties from liability for any damage that may result from furnishing such information to you.

 
Applicant Signature:________________________________________________ Date:__________________________________
 

EQUAL EMPLOYMENT OPPORTUNITY

Outreach Health Services is committed to providing equal opportunity to all qualified employees and applicants for employment. No employee or applicant will be discriminated against on the basis of race, color, religion, gender, national origin, age, ancestry, veteran status, marital status, disability and other factors prohibited by state and federal laws.

 
 
To Whom it May Concern:
 

I hereby authorize and request any present or former employer, school, police department, financial institution or other person having personal knowledge about me, to furnish bearer with any and all information in their possession regarding me in connection with an application for employment. A photocopy of this authorization may be accepted with the same authority as the original, and I specifically waive any written notice from any present or former employer who may provide information based upon this authorized request. I understand this authorization is to be part of the written application that I sign.

 
Printed Name:_______________________________________________ Social Security Number:_________________________
 
Applicant Signature:________________________________________________ Date:__________________________________
 
 

I certify that all information given is true and complete, and that I have accounted for all work experience and training for the last 10 years. I understand that misrepresentation or omission of information may cause for cancellation of my consideration for employment or termination, if already employed, and that employment may also be contingent upon my ability to perform specific job-related duties, with or without accommodation. I further understand that this is an employment "at will" application, and that no employment contract is being offered. If employed, such employment is for an indefinite period of time and is subject to changes in wages, conditions, benefits, and operating requirements. I further acknowledge that employment is contingent on I-9 verification of eligibility of employment. I understand that Outreach Health Services is a voluntary non-subscriber to Workers Compensation in Texas.

 
Applicant Signature:________________________________________________ Date:__________________________________
 
FOR OFFICIAL USE ONLY
 
OFFICE LOCATION:__________________________________    DATE INTERVIEWED:________________________________
DATE APPLICATION RECEIVED:_______________________    INTERVIEWED BY:__________________________________
APPLICATION RECEIVED BY:_________________________    SIGNATURE:________________________________________
SIGNATURE:________________________________________   DATE HIRED:________________________________________