Application for Employment

We are pleased that you are seeking employment with AccelHealth (AHC). We are an equal opportunity employer. We do not discriminate in employment on the basis of race, color, national origin, sex, age, religion, disability, or any other basis prohibited by federal, state, or local laws. Individuals with disabilities will be provided reasonable accommodations where necessary for the application process or the performance of essential job duties.

In order for you to be considered for employment, this application must be filled out in its entirety. Resumes are welcomed, but should not be submitted in lieu of any information requested below. Please attach additional pages, if necessary.

General

• Application Date: Month / Day / Year
• Position Sought: Must be specific. We do not consider applications that state “any available position”.
• Name: Last, First, Middle
• Do you have a Social Security Number? Y or N
• Street Address, City, State, Zip
• Telephone Number
• Previous Address: If less than 5 years at current address
• E-mail address
• May we contact your employer? Yes, No, N/A
• Relatives employed by AHC
• Are you legally eligible to work in the U.S.? Yes or No
• Starting Salary Expected: $
• Date Available for Employment: Month / Day / Year
• Do you smoke? Yes or No
• Are you bilingual for any language?
• Do you read and write any language?
• Have you ever applied to or worked for AHC? Yes or No
• Position
• Date: Month / Day / Year
• Are there any limitations on your working hours? Yes or No
• Will you work evenings? Weekends?
• Have you ever been sanctioned or disciplined by any federal, state, or local law enforcement, regulatory, or licensing agency? Yes or No
• If yes, explain date and type of discipline
• Are you now under investigation by any federal, state, or local law enforcement, regulatory, or licensing agency? Yes or No
• If yes, explain date and type of investigation
• Have you ever been convicted or sentenced to deferred adjudication for any criminal offense? Yes or No
• If yes, list date and type of offense(s)
• Convictions will not necessarily exclude you from employment, but will be reviewed in light of all circumstances, including date, age, and nature of violation.
• List all job related skills, including computer software, hardware, office machines, and similar items.

CTHC use only:

Education

Type of School	Name of School	City and State	Major Course of Study	Last Year Completed	Diploma or Degree	Grade Average
High School				9, 10, 11, 12
College				1, 2, 3, 4
Post Graduate
Other

Extracurricular activities: Exclude activities relating to race, religion, national origin, gender, age, or disability.

Leadership positions held: Exclude activities relating to race, religion, national origin, gender, age, or disability.

Military Experience

N/A

• Service Branch
• Dates: Month / Day / Year
• Rank at Discharge
• Type of Discharge
• Skills Acquired

Business Experience

• Have you ever been discharged or asked to resign from any position? Yes or No. If yes, explain where, when, and why.
• Have you ever been suspended or placed on probation by an employer for attendance, job performance, or conduct? Yes or No. If yes, please explain.
• Please explain all periods of unemployment.
• Do you have any other job that you would expect to continue if employed here? Yes or No. If yes, please explain.
• Please list any other business or companies in which you are involved or have a financial interest.

Job Experience

Full and part-time, starting with most recent. You must list all employers for at least the past ten years.

Present or Most Recent Employer

• From
• To
• Name and Title of Immediate Supervisor
• Street Address
• Telephone Number
• Your Position(s)
• City, State, Zip
• Wage or Salary: $
• Reason for Leaving

Previous Employer

• From
• To
• Name and Title of Immediate Supervisor
• Street Address
• Telephone Number
• Your Position(s)
• City, State, Zip
• Wage or Salary: $
• Reason for Leaving

Previous Employer

• From
• To
• Name and Title of Immediate Supervisor
• Street Address
• Telephone Number
• Your Position(s)
• City, State, Zip
• Wage or Salary: $
• Reason for Leaving

Previous Employer

• From
• To
• Name and Title of Immediate Supervisor
• Street Address
• Telephone Number
• Your Position(s)
• City, State, Zip
• Wage or Salary: $
• Reason for Leaving

Previous Employer

• From
• To
• Name and Title of Immediate Supervisor
• Street Address
• Telephone Number
• Your Position(s)
• City, State, Zip
• Wage or Salary: $
• Reason for Leaving

Professional References

List four individuals who can discuss your work history and job performance.

Name/Title	Company Name	Phone Number

Driving Data

Complete this section only if driving a motor vehicle is a duty of the position for which you are applying. If in doubt, ask.

• Type of Driver’s License
• Years of Driving Experience
• License Number
• Expiration Date
• State
• Have you ever had a driver’s license revoked or suspended? Yes or No
• If yes, when?
• Reason(s)
• List any major accidents you have had.

Motor Vehicle Violations for the Last Three Years

Type of Violation	City/County and State	Date	Disposition

Acknowledgment

Read carefully

I certify that the facts set forth above in my application and any resume I have submitted are true and correct. I understand that any false statements, misrepresentations, or omissions on this application, my resume, or any other AHC document shall be considered a sufficient basis for rejection of my application and for dismissal if hired, regardless of when discovered. In the event of my employment with AHC, I agree to conform to the rules and regulations of AHC and acknowledge that these rules and regulations may be changed, interpreted, withdrawn, or added to by AHC at any time, at AHC’s option and without prior notice to me. I understand that this application will be given every consideration, but its receipt does not imply that I will be employed. I also understand that if I am employed, my employment will be at-will, meaning that employment may be terminated by me or the company for any or no reason, with or without cause, at any time. I further understand that nothing in this application is to be considered in any way as a contract of employment. I acknowledge and agree that any statement or representation, whether written or oral, past or present, which is contrary to my right and AHC’s right to an at-will employment relationship is void and unenforceable and should not be relied upon in the absence of a written contract of employment signed by the Chief Executive Officer of AHC.

I hereby authorize AHC to conduct any investigation it deems necessary regarding my application. I also hereby authorize AHC to gather and to release information about me, together with their opinion on these matters, without any liability for any damage whatsoever caused either directly or indirectly by giving or receiving such information or opinions. I authorize any former employer, present employer, schools, colleges, and universities, personal references, and any other person or persons, to disclose to the company any information or opinions they may have concerning me, my character, or my employment record. I hereby unconditionally release AHC, any former employers, their agents and employees, and all references listed in this application from any and all claims, demands, or liabilities arising out of or related to such investigation or disclosure, including liability arising from negligence.

I understand that AHC may, in the course of its investigation of my application, obtain an investigative consumer report on me, as defined in the Fair Credit Reporting Act, and I understand that such report may include information as to my character, general reputation, personal characteristics, working skills and abilities, and mode of living. I understand that AHC is required to furnish to me upon proper request and within a reasonable time, according to the law, the nature and scope of the investigation.

Signature of Applicant

Date

This application will not be considered unless signed.

Revised January 2019