Employment Application

Personal Information
Today's Date
Social Security Number
Your name
First Last
Email
Your Address
Street Address City State ZIP Code
Home Phone
Cell Phone
Referred by
Relative's Department
Relative's Name
First Last
If related to anyone in our employ, state name. State their department in next field.
Resume Upload
Please upload your resume here. Acceptable formats as follows:
- PDF
- Word Doc (doc, docx)
- Text file (.txt)
File

Former Employers
List below your last four employers, starting with the LAST one first, whether temporary, seasonal, paid, unpaid, or voluntary.
Date
Name of Employer
Address
Street Address City State ZIP Code
Employer's Phone
Supervisor's Name
Your Position
Your Salary
Reason for Leaving?
Date
Name of Employer
Address
Street Address City State ZIP Code
Employer's Phone
Supervisor's Name
Your Position
Your Salary
Reason for Leaving?
Date
Name of Employer
Address
Street Address City State ZIP Code
Employer's Phone
Supervisor's Name
Your Position
Your Salary
Reason for Leaving?
Date
Name of Employer
Address
Street Address City State ZIP Code
Employer's Phone
Supervisor's Name
Your Position
Your Salary
Reason for Leaving?

References
Give the names of three persons, not related to you, whom you have known for at least one year.
Referral's Name
First Last
Referral's Phone
Referral's Address
Street Address City State ZIP Code
Referral's Business
Years acquainted
Referral's Name
First Last
Referral's Phone
Referral's Address
Street Address City State ZIP Code
Referral's Business
Years acquainted
Referral's Name
First Last
Referral's Phone
Referral's Address
Street Address City State ZIP Code
Referral's Business
Years acquainted

Security information
Have you ever been convicted of a felony or misdemeanor other than a minor traffic offense? (Conviction of a felony or misdemeanor will not automatically disqualify an applicant for employment. All circumstances will be considered in evaluating an applicant's suitability for employment.)
Conviction?
- No
- Yes
If yes, list date, city, charge and disposition
Are you a citizen of the United States, or have the legal right to be in this country?
- Yes
- No

Please Read Before Signing
Continuing Healthcare Solutions, Inc. does not discriminate on the basis of race, creed, national origin, sex, color, age or non-job related handicap or disability. Continuing Healthcare Solutions, Inc. insists that all of its employees can perform the essential functions of their employment and have the character, integrity and general reputation for honesty of a person that Continuing Healthcare Solutions, Inc. would have represent it in its dealings with customers, suppliers and/or other employees. Accordingly, we insist on complete honesty. ANY LATER DISCOVERY THAT AN APPLICANT WAS NOT HONEST IN COMPLETING THIS APPLICATION WILL BE GROUNDS FOR DISCHARGE.

Certification and Authorization- Please Read Thoroughly
I certify that all facts contained in the application are true and complete and acknowledge that Continuing Healthcare Solutions, Inc. is relying on the accuracy of the information provided. I authorize Continuing Healthcare Solutions, Inc. to verify the accuracy of the information herein, and I authorize that falsification, misrepresentation or omission of requested facts may result in denial of employment or, if employed, may result in immediate dismissal. I understand and agree that, if hired, my employment will be for no definite period and may, regardless of the date of payment of wages, be terminated at any time without previous notice and with or without reason, at the will of either Continuing Healthcare Solutions, Inc or myself. I also understand and agree that no one has authority to promise me job security or continued employment.
Electronic Signature*
First Last
Entering your name here as well as the security Captcha will confirm you're a human.
Date
Captcha
Name
This field is for validation purposes and should be left unchanged.

Personal Information