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Employment Application

"*" indicates required fields

Personal Information

Name:*

First Last

Address:*

Street Address Address Line 2 City State ZIP Code

Phone:*

Email:*

Are you legally eligible to work in the US?*

Yes

No

Are you a veteran?*

Yes

No

If selected for employment are you willing to submit to a background check?*

Yes

No

Professional License/Certification and CPR Information:

(Type, State, Number)

Position:

Position you are applying for:

Alternative position you are applying for:

Available Start Date:

Month

Day

Year

Desired Pay:

Employment Desired:

Full time

Part time

Contractual

Shift Availability:

Day

Evening

Nights

Weekend

Skills as they relate to interested position(s):

How did you hear of job vacancy?

Education:

School Name:

Location:

Years Attended:

Degree Received:

Major:

School Name:

Location:

Years Attended:

Degree Received:

Major:

School Name:

Location:

Years Attended:

Degree Received:

Major:

School Name:

Location:

Years Attended:

Degree Received:

Major:

References:

Reference #1 Name:

First Last

Title:

Company:

Phone:

Reference #2 Name:

First Last

Title:

Company:

Phone:

Reference #3 Name:

First Last

Title:

Company:

Phone:

Reference #4 Name:

First Last

Title:

Company:

Phone:

Employment History:

Employer #1:

Job title:

Start Date:

Month

Day

Year

End Date:

Month

Day

Year

Work Phone:

Starting Pay Rate:

Ending Pay Rate:

Address:

Street Address Address Line 2 City State ZIP Code

Employer #2:

Job title:

Start Date:

Month

Day

Year

End Date:

Month

Day

Year

Work Phone:

Starting Pay Rate:

Ending Pay Rate:

Address:

Street Address Address Line 2 City State ZIP Code

Employer #3:

Job title:

Start Date:

Month

Day

Year

End Date:

Month

Day

Year

Work Phone:

Starting Pay Rate:

Ending Pay Rate:

Address:

Street Address Address Line 2 City State ZIP Code

Employer #4:

Job title:

Start Date:

Month

Day

Year

End Date:

Month

Day

Year

Work Phone:

Starting Pay Rate:

Ending Pay Rate:

Address:

Street Address Address Line 2 City State ZIP Code

Employer #5:

Job title:

Start Date:

Month

Day

Year

End Date:

Month

Day

Year

Work Phone:

Starting Pay Rate:

Ending Pay Rate:

Address:

Street Address Address Line 2 City State ZIP Code

Signature Disclaimer:

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my employment being terminated.*

I agree

Signature:*

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In recognition of Black History Month and Stoddard’s History, Mr. Steven Nash, President and CEO, participated in the Health Policy Breakroom Podcast with Host, Ms. Kayla Holgash, Health Policy Director of Health Equity and Medicaid Policy.

Hear This Live Interview