Employment Application

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If you are experiencing difficulties completing the online application, please complete the fillable application and return to humanresources@highlandclinic.com or fax to 318-798-4555

Step 1 of 7

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Employment Desired

Position Desired(Required)

Hourly Rate Desired(Required)

Are you seeking(Required)

Full Time

Part Time

Temporary

Date You Can Start(Required)

Personal Information

Incomplete information could disqualify you from further consideration.

Name(Required)

First Middle Last

Today's Date(Required)

Email Address(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone(Required)

Are you eligible to work in the United States?(Required)

Yes

Are you at least 18 years of age or older?(Required)

(If no, you may be required to provide authorization to work.)

Yes

Can you work any shift?(Required)

Yes

Can you work overtime, including weekends?(Required)

Yes

Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?(Required)

(If you are unsure of the essential functions, please ask to review a job description.)

Yes

Referral Source

How did you hear about us?(Required)

Walk-In

Referral (Name)

Other

Referral Name(Required)

Have you ever worked for this company?(Required)

If yes, please provide dates, supervisors, etc.

Yes

Provide dates, superviors, etc.(Required)

Do you know anyone who works for this company?(Required)

If yes, please provide name and length of time known for each

Yes

Provide name and length of time known for each person(Required)

Do you have any relatives currently working for this company?(Required)

If yes, please provide name and relationship for each

Yes

Provide name and relationship for each(Required)

Are you currently employed?(Required)

Yes

If yes, may we contact your present employer?(Required)

Yes

Have you ever been terminated from employment or asked to resign by an employer?(Required)

If yes, please provide the company names and contacts

Yes

Names and contacts of previous employment that you were terminated from(Required)

Have you ever been convicted of a felony offense?(Required)

(A conviction will not necessarily disqualify you for employment. Rather, such factors as age, date of conviction, seriousness, and nature of the crime will be considered.) If yes, please provide dates and location for all convictions:

Yes

Dates and locations for all convictions(Required)

Employment History

Include your last three positions (or your last ten (10) years of employment history), including periods of unemployment, starting with the most recent and working backwards in time. (Incomplete information could disqualify you from further consideration.)

Current or Most Recent Employer

Employed From

Employed To

Starting Salary

Ending Salary

Company Name

May we contact

Yes

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number

Position Title

Supervisor

Supervisor's Title

Nature of the Work Performed and Position Responsibilities

Reason for Leaving

Second Most Recent Employer

Employed From

Employed To

Starting Salary

Ending Salary

Company Name

May We Contact

Yes

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number

Position Title

Supervisor

Supervisor's Title

Nature of the Work Performed and Position Responsibilities

Reason for Leaving

Third Most Recent Employer

Employed From

Employed To

Starting Salary

Ending Salary

Company Name

May We Contact

Yes

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number

Position Title

Supervisor

Supervisor's Title

Nature of the Work Performed and Position Responsibilities

Reason for Leaving

Education

High School

Name of School

City/State

No. Years Attended

Subjects/Major

Degree Y/N

College or University

Name of School

City/State

No. Years Attended

Subjects/Major

Degree Y/N

Graduate School

Name of School

City/State

No. Years Attended

Subjects/Major

Degree Y/N

Trade or Business School

Name of School

City/State

No. Years Attended

Subjects/Major

Degree Y/N

Licenses or Certifications

Name/Type

Issued By

Issued Date

Expiration Date

Special skills, experience and/or training that would enhance your ability to perform the position applied for

Equipment and/or Computer Skills

References

(Provide names/addresses/phone numbers of three persons, not related to you, whom you have known at least three (3) years.)

Name

Address/Phone

Occupation

# Years Known

Upload Your Resume

Upload your resume in .pdf, .doc or .docx format

Accepted file types: pdf, doc, docx, Max. file size: 25 MB.

Acknowledgement

It is the policy of Highland Clinic, APMC to provide equal employment opportunity to all qualified persons without regard to citizenship, race, color, creed, religion, gender, sexual orientation, age, national origin, marital status, disability, or veteran status. This application will be given every consideration, but its receipt does not imply that there are any open positions or that the applicant will be employed. Only applicants meeting the minimum requirements for a position as determined by the company will be considered for employment. Should more than one qualified person make application, the company reserves the right to select the applicant that, in its opinion, possesses the best qualifications.

In making this application for employment an investigative consumer report may be prepared whereby information is obtained through personal interviews with neighbors, friends, or other acquaintances. Such an inquiry would include information as to character, general reputation, personal characteristics, and mode of living of the applicant. An applicant has the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation.

Authorization

Please Read Carefully Before Signing

I authorize investigation of all statements contained in this application (if I am considered for employment) and hereby authorize previous employers, personal references named, or any other person or persons to whom the company may refer, to give any and all information regarding my background if requested.

If employed, I agree to engage in no outside activity which would involve a material conflict of interest with, or which could, as determined by the company, reflect adversely on the company.

If employed, I agree to maintain confidentiality regarding any information concerning the company that may come to my knowledge. Further, I agree to comply with all of the policies and regulations of the company as set forth in the company’s employee handbook or other communications distributed to all employees.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. I understand that if employment is offered to me, either verbally or in writing, such offer does not constitute a contract of employment. I understand that if I am employed by the company my employment will be for no definite period of time and that my employment can be terminated at any time and for any reason, with or without cause and without prior notice, at the option of either the company or myself. I also understand that this status can only be altered by a written contract of employment, specific to all material terms, that is signed by an authorized officer of the company

I attest with my signature below that I have read all of the above statements and understand the same and that all statements made by me are true and accurate to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that any false statements or material omissions may be grounds for refusal to hire, or for immediate dismissal. I certify that I am at least 18 years of age and am legally authorized to work in the United States. Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between myself and the company for either employment or for the providing of any benefit.

I understand that as a condition of this application and any employment, I may be required to submit to testing for the presence of illegal drugs. I hereby consent to such testing. I further acknowledge that no promise or guarantee is binding upon the company unless made in a written contract of employment as described above.

Apllicant's Name(Required)

(Please Print)

Signature(Required)

Date(Required)

THIS APPLICATION IS VALID ONLY FOR 60 DAYS FROM THE DATE SIGNED/DATED ABOVE.