Employment

State Health Inc.

Registration Form

To download application click here for a pdf.

Fill out form below

Applicant Information

Full Name:

Address:

City: State: Zipcode:

Phone:

Email:

Date Available :

Social Security No:

Desired Salary: $

Position Applied for:

Are you a citizen of the United States? yes no

If no, are you authorized to work in the U.S.? yes no

Have you ever worked for this company? yes no

If yes when? yes no

Have you ever been convicted of a felony? yes no

If yes, explain:

 

Education

High School :

Address:

From: To :   Did you graduate? yes no   Degree:


College :

Address:

From: To :   Did you graduate? yes no   Degree:


Other :

Address:

From: To :   Did you graduate? yes no   Degree:

 

References

Full Name: Relationship:

Company: Phone:

Address:

___________________________________________________________________________

Full Name: Relationship:

Company: Phone:

Address:

___________________________________________________________________________

Full Name: Relationship:

Company: Phone:

Address:

 

Previous Employment

Company: Phone:

Address:

Supervisor :

Job Title: Starting Salary: $ End Salary: $

Responsibilities:

From: To :  Reason for Leaving :

May we contact your previous supervisor for a reference? yes no  

__________________________________________________________________________

Company: Phone:

Address:

Supervisor :

Job Title: Starting Salary: $ End Salary: $

Responsibilities:

From: To :  Reason for Leaving :

May we contact your previous supervisor for a reference? yes no  

___________________________________________________________________________

Company: Phone:

Address:

Supervisor :

Job Title: Starting Salary: $ End Salary: $

Responsibilities:

From: To :  Reason for Leaving :

May we contact your previous supervisor for a reference? yes no  

 

Military Service

Branch:

From: To :  Type of Discharge :

In other than honorable, explain:

Disclaimer

I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in the dismissal at any time. I authorize the company to make an investigation concerning my background or any facts set forth in this application. I hereby release the Company, any agent appointed be the Company, and all their respective employees and employers from any liability related to or arising of the exchange of such information. I understand that employment at this Company is “at will”, which means that either the company or I can terminate the employment relationship at any time, with or without prior notice, and with or without cause. All employment is continued on that basis.

     

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