Careers Form

* = Required Information

Our policy is to provide equal employment opportunity to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, ancestry, physical or mental disability, or veteran status.

Date*

Last Name*

First Name *

Middle Name *

Street Address *

Apt#

City*

State *

Zip *

Telephone

Social Security #

Are you looking for

Full-Time

Part-Time

How did you hear of this opening?

Have you ever been employed with Apex Health Care Solutions LLC?

Yes

Date Available

Desired Salary

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

Yes

(If No, proof of U.S. Citizenship or immigration status will be required upon employment)

Have you ever been sanctioned by the Office of the Inspector General for fraud, abuse or any other reason?

Yes

If no, please explain

Have you ever been convicted of a felony? (This will not necessarily affect your application.)

Yes

Have you ever been convicted of a crime? (This will not necessarily affect your application.)

Yes

If offered a position, do you agree to submit to a drug screen?

Yes

If no, please explain

Educational Background

High School

School Name and Location

Year

Major

Degree

College

School Name and Location

Year

Major

Degree

College

School Name and Location

Year

Major

Degree

Post-College

School Name and Location

Year

Major

Degree

Other Training

School Name and Location

Year

Major

Degree

Additional Skills

In addition to your work history, are there other skills, qualifications, or experience that we should consider?

Employment History (Start with most recent employment)

Company Name

Address

Phone

Date Started

Starting Wage

Starting Position

Date Ended

Ending Wage

Ending Position

Name of Supervisor

May we contact?

Yes

Responsibilities

Reason for leaving

Company Name

Address

Phone

Date Started

Starting Wage

Starting Position

Date Ended

Ending Wage

Ending Position

Name of Supervisor

May we contact?

Yes

Responsibilities

Reason for leaving

Company Name

Address

Phone

Date Started

Starting Wage

Starting Position

Date Ended

Ending Wage

Ending Position

Name of Supervisor

May we contact?

Yes

Responsibilities

Reason for leaving

Company Name

Address

Phone

Date Started

Starting Wage

Starting Position

Date Ended

Ending Wage

Ending Position

Name of Supervisor

May we contact?

Yes

Responsibilities

Reason for leaving

I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements on this application shall be considered sufficient cause for dismissal. Apex Health Care is hereby authorized to make any investigations of my prior educational and employment history.

I understand that employment at Apex Health Care Solutions LLC is "at will," which means that either I or Apex Health Care Solutions LLC can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no supervisor, manager, except the executive of this company, has any authority to alter the foregoing.

Full Name

Date

Attach Resume