Name: AccelHealth
Price range: $

"*" indicates required fields

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:*

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?*

YES

Address*

City:*

State:*

Zip:*

Previous Address:

(If less than 5 years at current address)

Phone:*

Email:

May we contact your employer?

YES

N/A

Relatives employed by AHC:

Are you legally eligible to work in the U.S.?

YES

Starting Salary Expected:

Date Available for Employment:*

Do you smoke?

YES

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

If yes, provide dates and reasons?

List any major accidents you have had:

LIST ALL MOTOR VEHICLE VIOLATIONS FOR THE LAST THREE YEARS

HAVE YOU HAD ANY MOTOR VEHICLE VIOLATIONS FOR THE LAST THREE YEARS

YES

Type of Violation:

City/County and State:

Date:

Disposition:

Add Violation 1

Add Violation

Type of Violation:

City/County and State:

Date:

Disposition:

Add Violation 2

Add Violation

Type of Violation:

City/County and State:

Date:

Disposition:

Add Violation 3

Add Violation

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/or 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*

(This application will not be considered unless signed)

Date*

Revised October 2021

Name

This field is for validation purposes and should be left unchanged.