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Employment Application

 

 

 

 

Position(s) Applied For:
Referral Source:
Your Name: (Last / First / Middle)
 Name of Source:
Address (Street):
City:
State:
Zip:
E-mail:
Telephone:
Mobile/Beeper/Other:
Best Time to Call:
May We Contact You at Work?
Work Phone:
If You Are Under 18 and It Is Required, Can You Furnish a Work Permit?
 
Have You Submitted an Employment Application Here Before?
If Yes, Give Date:
Ex. 01/08/01
Have You Ever Been Employed at Pyramid Healthcare Before?
If Yes, Give Dates:
Ex. 12/01/97-12/01/00
Are You Legally Eligible for Employment in the United States?
What Date Will You Be Available to Begin Employment?
Ex. 01/08/01
What Type of Employment Are You Looking to Achieve?
Will You Be Willing to Relocate If Your Job Requires You to Do So?
Are You Able to Meet All Attendance Requirement of the Position?
If Your Job Requires You to Work Over-Time Are You Willing to Do So?
  If Your Job Requires You to Work Over-Time Are You Willing to Do So?
Are You Able to Meet All Attendance Requirements of the Position?
If No, Please Explain:
Have You Ever Been Convicted of a Crime Within the Last Seven Years?
If Yes, Please Explain:
Have You Ever Been Legally Bonded?
 
If Driving Is An Essential Job Function, Please Provide D.L.# and State.
Drivers License #:
Issuing State:
Employment History
Provide the following information for your past and current employers, assignments or volunteer activities, starting with the most recent.  Explain any gaps in employment in comments section below.
Most Recent Employer:
Telephone:
Address:
Job Title:
Immediate Supervisor:
 
Dates Employed:
From:
Ex. 12/08/98
 To:
Salary Per Year:
Starting:
If hourly and full time, multiply hourly rate times 2080.  If part-time, multiply hourly rate times hours in a week, times 52.
 Final:
Work Performed and Job Responsibilities:
Reason for Leaving:
May We Contact for Reference?
 
   
Next Employer:
Telephone:
Address:
Job Title:
Immediate Supervisor:
 
Dates Employed:
From:
Ex. 12/08/98
 To:
Salary Per Year:
Starting:
If hourly and full time, multiply hourly rate times 2080.  If part-time, multiply hourly rate times hours in a week, times 52.
 Final:
Work Performed and Job Responsibilities:
Reason for Leaving:
May We Contact for Reference?
 
   
Next Employer:
Telephone:
Address:
Job Title:
Immediate Supervisor:
 
Dates Employed:
From:
Ex. 12/08/98
 To:
Salary Per Year:
Starting:
If hourly and full time, multiply hourly rate times 2080.  If part-time, multiply hourly rate times hours in a week, times 52.
 Final:
Work Performed and Job Responsibilities:
Reason for Leaving:
May We Contact for Reference?
 
Comments - Including Explanation of Any Gaps in Employment:
 
Skills & Qualifications:

Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.
Educational Background:
School:
Number Years Completed:
Degree or Diploma:
G.P.A./Class Rank:
Major:
Minor:
School:
Number Years Completed:
Degree or Diploma:
G.P.A./Class Rank:
Major:
Minor:
School:
Number Years Completed:
Degree or Diploma:
G.P.A./Class Rank:
Major:
Minor:
References: List name and telephone numbers of three business/work references who are not related to you and are not previous supervisors.  If non-applicable, list three school or personal references who are not related to you.
Name, Telephone, & Years Known:
Name, Telephone, & Years Known:
Name, Telephone, & Years Known:
 
Additional Information:
List professional, trade, business, or civic associations and any offices held.  Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or any other similarly protected status.
Organization:
Offices Held:
Organization:
Offices Held:
Organization:
Offices Held:
List Special Accomplishments, Publications, Awards, Etc.
List Any Additional Information You Would Like Us to Consider:

© 2003 - Pyramid Healthcare

Pyramid Healthcare is licensed by the State of Pennsylvania Department of Health, Division of Drug & Alcohol Programs Licensing, the Pennsylvania Department of Public Welfare, Office of Children, Youth and Families and the Office of Mental Health. Many of our facilities are JCAHO Accredited. Information on JCAHO accredited organizations may be obtained by calling 800-994-6610. We do not discriminate against any patient in relation to admission, treatment, discharge, continuing care or employment based on race, color, religion, creed, national origin, sex, disability (including limited English proficiency) or sexual orientation. We offer priority admission to at-risk populations including:  women, women with children, pregnant women, IV drug users and adolescents.