Job Application | Graham Health Systems

Apply for Clinical Supervisor

Page 1

Personal Information

First Name *

Middle Name

Last Name *

Any Previous Names (including Maiden name)

Current Address *

City State Zip

City *

State *

Zip Code *

Phone Number Email

Phone Number *

Email *

Are you applying for full-time or part-time? *

Full-Time
Part-Time

Page 2

Job Applied For

Annual Salary Desired *

Have you ever been employed by this facility?

If yes, when?

Do you have friends or relatives employed by this facility?

Friend/Relative Details

1	Friend/Relative Name Department Relationship
1	Friend/Relative Name Department Relationship

Add Friend/Relative

Are you 18 years of age or older? *

Are you a US Citizen or Alien legally authorized to work in the United States? *

Long Range Occupational Goals

Page 3

Education/Skills

Other Business College or Special Courses

Special Military Training, Post Graduate and Nursing

Area(s) of specialization or major interest

List office skills including computer/software experience

Word Processing (Approx. WPM)

Page 4

Professional Licenses

Professional License or Registration

Currently Licensed
Currently Registered
Eligible for License
Eligible for Registration

Professional License or registration ever suspended, revoked, or on probation?

Type

State

Number

License Date

Professional Certifications

Currently Certified
Eligible for Certification

Type

State

Date

Page 5

Previous Experience

Upload Resume

File name:

File size:

Briefly Describe duties and skills acquired through military or volunteer service: (include dates)

Provide information regarding previous employment beginning with most recent employer.

To add an employer, click "add employer" at the bottom of this section. To remove an employer, click the minus sign to the right of the employer you would like to delete.

1	Job Title * From * To * Supervisor's Name * Company Name * Address Duties * Reason for Leaving *
2	Job Title * From * To * Supervisor's Name * Company Name * Address Duties * Reason for Leaving *
1	Job Title * From * To * Supervisor's Name * Company Name * Address Duties * Reason for Leaving *

Add Employer

Please identify and explain any gaps in employment longer than three (3) months *

Page 6

Language Skills

Do not complete unless requested.

Page 7

References

List at least three (3) references who are not relatives

To add a reference, click "add reference" at the bottom of this section. To remove a reference, click the minus sign to the right of the reference you would like to delete.

1	Name & Relationship * Title * Company Name & Address Phone Number * Email *
2	Name & Relationship * Title * Company Name & Address Phone Number * Email *
3	Name & Relationship * Title * Company Name & Address Phone Number * Email *
1	Name & Relationship * Title * Company Name & Address Phone Number * Email *

Add Reference

Page 8

Authorization

Carefully read this section prior to hitting submit.

Message

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete.

I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date. I understand that I will be required to satisfactorily complete a drug, alcohol and tobacco use screening as a condition of employment.

Graham Health System is committed to providing a safe and healthy work environment and to promote the health and well-being of their employees.

Authorization 1 *

I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information. *

Authorization 2 *

I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized. *

Authorization 3 *

I hereby acknowledge that I have read the above statements, understand them and agree with them. *

1	Language Do you speak? Fair Good Fluent Do you read? Fair Good Fluent Do you write? Fair Good Fluent
1	Language Do you speak? Fair Good Fluent Do you read? Fair Good Fluent Do you write? Fair Good Fluent