Highway 190 W
Kinder, LA 70648
337-738-2527

Application for Employment

Personal Information

  
Last Name:
First Name:
Middle Initial:
SSN (no spaces or dashes):
Street Address:
City:
State:
Zip:
Phone:
Phone for Message:
Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime in this state or any other state? (excluding traffic violations)?
Yes No

If yes, please explain.
Have you ever been refused a surety bond for dishonesty? Yes No
Have you ever been involuntarily discharged?  
Yes No

If yes, explain and give dates:

Placement Information

  
1st Position Applied For:
2nd Position Applied For:
Positions Applied For (Check Those Applicable) Full time (32-40 Hours) Part Time (1-32 Hours)
Are you available to work: Overtime Weekends Nights
When will you be available to begin work?
Check each item in which you have training: Typing wpm
  Transcribing
  Calculator spm
  Bookkeeping
  Word Processing
  VDT
  Personal Computers
  Others:

Education

  
High School:
Grade Completed: 9 10 11 12
Graduated: Yes No
Type of Diploma or Degree:
Major and Minor Fields of Study:
 
 
College:
Years Completed: 1 2 3 4
Graduated: Yes No
Type of Diploma or Degree:
Major and Minor Fields of Study:
 
  
Graduate School:
Years Completed: 1 2 3 4
Graduated: Yes No
Type of Diploma or Degree:
Major and Minor Fields of Study:
 
  
Vocational or Other School:
Years Completed: 1 2 3 4
Graduated: Yes No
Type of Diploma or Degree:
Major and Minor Fields of Study:

Licenses

 PROFESSIONAL LICENSES, REGISTRATIONS AND/OR CERTIFICATES
Type:
State of Issue:
Date Issued:
License Number:
Type:
State of Issue:
Date Issued:
License Number:
Type:
State of Issue:
Date Issued:
License Number:
Area of Specialization or Interest:

Employment History

 
Current Employer:
Phone:
Street Address:
City:
State:
Zip:
Supervisor:
Dates (Month & Year): From: To:
Base Earnings:
Duties:
Reason for Leaving:
Previous Employer:
Phone:
Street Address:
City:
State:
Zip:
Supervisor:
Dates (Month & Year): From: To:
Base Earnings:
Duties:
Reason for Leaving:
Previous Employer:
Phone:
Street Address:
City:
State:
Zip:
Supervisor:
Dates (Month & Year): From: To:
Base Earnings:
Duties:
Reason for Leaving:
Previous Employer:
Phone:
Street Address:
City:
State:
Zip:
Supervisor:
Dates (Month & Year): From: To:
Base Earnings:
Duties:
Reason for Leaving:
   

References

 Give name(s) of persons we may contact to verify your qualifications for the position.
Name:
Address:
Phone:
Occupation:
Organization:
Name:
Address:
Phone:
Occupation:
Organization:
Name:
Address:
Phone:
Occupation:
Organization:

Submission of Application

  
  1. The information I have provided on this application is accurate to the best of my knowledge and subject to
    to validation by APH.
  2. Employment with APH is for no stated period of time or duration and APH or the employee may terminate
    the employment whenever either deems it best.
  3. I understand that any false information, omissions or misrepresentations of facts called for in this application
    may result in rejection of my application or discharge at any time during my employment.
  4. I authorize the company and/or its agents to verify any of its information including but not limited to criminal
    history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement
    agencies to release any information concerning my background.
Full Legal Name of Applicant:
Date of Application:

Thank you for completing this application. You can be assured that our review of your job qualifications will be based solely on merit and a final determination reached as quickly as possible.

PLEASE CHECK TO SEE THAT YOU HAVE ANSWERED ALL THE ABOVE QUESTIONS
   

U.S. Law requires that, if hired, you must furnish appropriate documentation establishing IDENTITY and EMPLOYMENT ELIGIBILITY. For example, acceptable documents include:

  • A U.S. Passport, Certificate of U.S. Citizenship, Certificate of Naturalization or INS Forms 688 or 688A;
  • A Social Security card or birth certificate issued by government authority and a driver's license, school I.D. with photo or other government issued documentation establishing identity.

Certain other documents are equally acceptable. Please consult a member of your management team and ask them for a copy of INS form I-9 for a list of these documents.
 
YOUR APPLICATION WILL BE CONSIDERED ACTIVE FOR SIX MONTHS. FOR CONSIDERATION AFTER THAT TIME PERIOD YOU MUST REAPPLY.
Allen Parish Hospital