Application For Employment

    If you are under the age of 18, can you furnish a work permit? YesNo

    Desired Work Schedule: Full TimePart TimeTempSeasonal

    Are you currently employed? YesNo

    If so, may we contact your current employer? YesNo

    Have you ever applied with this company before? YesNo

    Are you currently on layoff and subject to recall? YesNo

    Will you travel if required? YesNo

    Will you relocate if required? YesNo

    Are you able to meet attendance requirements of this position? YesNo

    Will you work overtime if required? YesNo

    Have you ever been bonded? YesNo

    Have you been convicted of a felony in the past 7 years? YesNo

    Any such conviction does not bar you from employment, however; may be relevant if it is job-related. If yes, please explain:


    Summarize any special skills and/or qualifications you have that may qualify you to work with us




    • Read and Write
    • Read and Speak
    • Speak Only
    • Read and Write
    • Read and Speak
    • Speak Only
    • Read and Write
    • Read and Speak
    • Speak Only
    • Read and Write
    • Read and Speak
    • Speak Only


    1. Reporting to work with impaired abilities; or the possession, consumption or distribution of drugs or alcohol on company premises and/or worksites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant or employee to agree to a physical examination, polygraph, and/or substance testing if required by the company. We are committed to operating a drug-free workplace. Violations or our drug and alcohol policy will result in dismissal.

    2. It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed. Furthermore, I understand that just as I am free to resign anytime, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.

    3. I give the employer the right to investigate all police, driving, and personal records and references if job-related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

    4. The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law.

    5. Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort, or contract claims, will be submitted to mediation, and failing settlement in mediation, to binding arbitration. Unless otherwise agreed, mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company panel of mediators and will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section 1-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce.

    6. This application is current for 60 days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application.

    By checking this box you acknowledge your understanding and agreement with all 6 of the above statements I have read and agree

    Entering your name in the field above constitutes as your legal "signature".

    Better Health Care is Our Mission

    We accept: medicare, worker’s comp, private insurance, private pay, and va pay