News Shadow

Employment Application

IHCS, Inc. Is An Equal Opportunity Employer
Items marked with an asterisk are required.
First Name *
Last Name *
Street/PO Box *
City *
State *
Zip *
Email
Home Phone *
Busness Phone
Referral Source
(Check all that apply)		 Ad
Friend
Relative
Walk-In
Other
Position(s) Applied For *
Job Type(s) Desired Full Time
Part Time
Per Diem
Expected Salary
Specify days and hours available *
Specify date available to begin work *
Have ever been employed with IHCS before? * yes
no
If yes, give date(s)
Have ever filled out an application with us before? * yes
no
If yes, give date(s)
Are you a U.S. Citizen? yes
no
Are you legally eligible for employment in the U.S.? * yes
no
Are you 18 years of age or older? * yes
no
Were you in the U.S. Armed Forces? * yes
no
Branch
Dates
Have you ever been convicted of a crime? *
(A yes answer does not automatically disqualify an applicant from employment).		 yes
no
If yes, please explain
Have you ever been convicted of a crime involving sexual abuse? * yes
no
If yes, please explain
Are there any unresolved complaints or reports of professional misconduct by you that are pending before any professional board or governmental agency? * yes
no
If yes, please explain
Will you work overtime if asked? * yes
no

Employment History

Start with your present or last job. Include any job-related military services assignments and volunteer activities.
Employer 1
Dates Employed To
Street/PO Box
City
State
Zip
Phone
Starting Salary
Final Salary
Supervisor
Job Title
Duties
Reason for leaving


Employer 2
Dates Employed To
Street/PO Box
City
State
Zip
Phone
Starting Salary
Final Salary
Supervisor
Job Title
Duties
Reason for leaving


Employer 3
Dates Employed To
Street/PO Box
City
State
Zip
Phone
Starting Salary
Final Salary
Supervisor
Job Title
Duties
Reason for leaving

References
Please list three professional persons, not related to you, that we may contact for references. Include name, address, and phone number.