GENERAL INFORMATION

EMPLOYMENT DESIRED

Type of Work Desired:* Full-time (60-80 hours per pay period)Part-time (39-59 hours per pay period)Temporary/PRN job

My shift preference:* Day ShiftEvening ShiftNight Shift

Are you willing to work weekends/holidays?* YesNo

EMPLOYMENT ELIGIBILITY

Are you 16 years or older?*
YesNo
Are you a U.S. Citizen?*
YesNo
If no, are you allowed to work in the U.S.?*
YesNo
Have you ever been convicted of a felony?*
YesNo
Have you received an approved COVID-19 vaccination?*
YesNo
Do you wish to receive the COVID-19 vaccination?*
(If no, you must submit a medical or religious exemption request (provided by AHC) within 5 business days prior to start of employment.)
YesNo
Have you reviewed the job description?*
YesNo
Are you able to perform the essential functions of the job you are applying for, with or without reasonable accommodation?*
YesNo
Explain any accommodations which we should consider before placement.

EDUCATION

High School or GED:

Did you graduate? YesNo

College:

Did you graduate? YesNo

Other:

Did you graduate? YesNo

Occupational License, Certificate or Registration:

WORK EXPERIENCES

Are you currently in a contract with a healthcare organization or recruitment firm?*
YesNo

Employer #1:

Employer #2:

Employer #3:

MILITARY STATUS

Are you currently a member of the National Guard?*
YesNo

EMPLOYMENT REFERRAL

Did someone at AHC refer you to this position? If yes, who?

How did you hear about the position you are applying for?*
Through a friendSocial Media (Facebook, Facebook Groups)School job board/careers websiteIndeedWord of Mouth

PROFESSIONAL REFERENCES

Reference #1

Reference #2

Reference #3

RESUME

Attach your Resume here:(pdf only)

DISCLAIMER AND SIGNATURE

I certify the information contained in this application is true, correct, and complete. I understand that, if employed, false statements reported on this application may be considered sufficient cause for dismissal. I authorize AHC to make an investigation of any of the facts set forth in this application and release AHC from any liability. AHC may contact any listed references or prior employment on this application. I acknowledge and understand that AHC is an “at will” employer. Therefore, any employee may resign at any time, just as the employer may terminate the employment relationship with any employee at any time, with or without cause, with or without notice to the other party.

Please enter you full name for electronic signature:

Ashland Health Center is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Ashland Health Center's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.