Reach Healthcare Services Application for Employment

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, martial or veteran status, sexual orientation, or any other legally protected status.

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How Did You Learn About Us?    *=REQUIRED
Newspaper    Internet    Recruiter    Friend/Relative    Walk-In
Last Name * First Name* Middle Initial Today's Date
Address * City, State, Zip * Phone * Alternate Phone *
Email Address: Social Security #    
   
Position for which you are applying:  
 
Have you ever been employed with us before? (if yes, give date) Are you currently employed?
Have you ever filed an application with us before? (if yes, give date) May we contact your present employer?
Have you ever been convicted of a felony within the last 7 years? (if yes, explain) * Are you currently on "lay-off" status and subject to call?
Are you authorized to work in the United States? *  
 
State any additional information you feel may be helpful to us in considering your application. Summarize special job-related skills & qualifications acquired from employment
Hours of Availability: Part-time Full-time Shift Work  Temp
What hours are you available to work? When can you start?
       

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Yes No Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied?
Note to Applicants:
Do not answer this question unless you have been informed about the requirements of the job for which you have applied.
School Name and Location Course of Study Dates Attended Degree/Diploma
High School
Undergraduate College
Graduate School
Other(specify)
         
Indicate any foreign languages you can speak/read/and/or write Describe any specialized training, apprenticeship skills and extra curricular activities:
Speak  
Read  
Write  
         
CLINICAL/HEALTH CARE APPLICANTS ONLY
Please check the specialty area(s) that best matches your education, experience & interest: Please check the shift(s) and days of the week that you are available to work:
Intermittent Care Pediatrics/maternal child
Med/Surg IV Therapy
Extended Care Rehabilitation
Full-time Part-time 7am-3pm 3pm-11pm 11pm-7am
_visits only Monday Tuesday Wednesday Thursday
Friday Saturday Sunday    
   

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Company Name Company Address City State Zip Code
Phone Number Position Held Dates of Employment Supervisor Starting Pay
Ending Pay Job Functions Reason for Leaving May we contact this employer?
Company Name Company Address City State Zip Code
Phone Number Position Held Dates of Employment Supervisor Starting Pay
Ending Pay Job Functions Reason for Leaving May we contact this employer?
Company Name Company Address City State Zip Code
Phone Number Position Held Dates of Employment Supervisor Starting Pay
Ending Pay Job Functions Reason for Leaving May we contact this employer?

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I certify that the information in this application is accurate, current and complete. I understand that misstatements or omissions may result in disqualification from further consideration or termination of employment. I also certify that my physical and emotional condition does not include any impairment, including habituation to substances that will prevent me from working at REACH.

I authorize REACH to conduct investigations in which information may be obtained through personal interviews with business associates, personal acquaintances, financial sources or other third parties regarding my employment history, credentials, character and credit background and to obtain any relevant information (including a criminal background check) needed to make my employment decision. I authorize REACH to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for local, state, federal, contractual or accreditation audit purposes. I also authorize REACH to disclose any of my performance appraisals, disciplinary records or skills tests for the same purposes as above. I release REACH and any individual or entity providing information to REACH from all liability for any damages from the disclosure of this information.

I also understand and agree that:

  • passing a medical examination and/or participating in a post-conditional offer medical screening may be required.
  • I may be subject to pre-employment drug testing or a drug test where a reasonable suspicion exists, or where warranted by circumstances, workplace conditions or contractual requirements.

I understand and agree that nothing contained in this employment application or in granting of an interview creates an employment contract between REACH and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be terminable “at will”, that I will have the right to terminate my employment at any time, and REACH will retain a similar right to terminate my employment at any time.

I understand and agree that this application is a continuous document and should any of the information, which I have supplied herein, change, I am obligated to notify REACH of such change immediately.

I understand that should I become employed by REACH my work assignments, schedules and/or work locations are subject to change according to the needs of the business and the clients of REACH


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   Signature Date