APPLICATION FOR EMPLOYMENT
Thank you for considering Acumentra Health in your job search. Acumentra Health is an equal employment opportunity employer and does not discriminate on the basis of race, age, color, sex, national origin, physical or mental disability, marital or veteran status, sexual orientation, or any other classification protected by law. No application will be rejected as a result or disability that, with reasonable accommodation, does not prevent performance of the essential job duties. After completing the application click on the "Submit Application" link at the bottom of the page.


Last Name:     First Name:     Middle:

Address:         Apt:        City:     State:     Zip:

1. Personal Information

Position Applied For:      

Salary Desired:                                                      Date You can Start::  

Home Phone:                                                             Work Phone:    
2. Education and Skills
Training Name of School
City and State		 Major Subjects
or
Type of Courses		 Last Year
Completed
(please mark)		 Did you Finish?
Checked/Yes Unchecked/No
High School    9   10    11    12  
  		 Graduate
 
College or University 1     2    3    4
 		 Degree
 
Additional Schooling /Training Number of Years
  Certificate
   


License/Certificate/Registration Number Issued By: Expiration Date

3. Work Experience

  Employer #1
From (Month/Year)
To (Month/Year)
Address
Telephone Number
Job Title
Supervisor's Name
Describe your duties and responsibilities
Starting salary
Ending salary
Reason for leaving


  Employer #2
From (Month/Year)
To (Month/Year)
Address
Telephone Number
Job Title
Supervisor's Name
Describe your duties and responsibilities
Starting salary
Ending salary
Reason for leaving


  Employer #3
From (Month/Year)
To (Month/Year)
Address
Telephone Number
Job Title
Supervisor's Name
Describe your duties and responsibilities
Starting salary
Ending salary
Reason for leaving


  Employer #4
From (Month/Year)
To (Month/Year)
Address
Telephone Number
Job Title
Supervisor's Name
Describe your duties and responsibilities
Starting salary
Ending salary
Reason for leaving


May we contact your present employer?       Yes     No 

4. General Information
 
Are you 18 years of age or older?

 Yes   No  

Do you have the legal right to work in the United States? (Successful applicants will be required to prove identity and eligibility for employment.)

 Yes   No  
Have you ever been employed or attended school using any other name? Yes   No  
If yes, please explain.

Have you ever been convicted, plead Guilty, or No Contest, or Forfeited Bond or Bail for any crime other than traffic violations? (Note: Applicants for positions in Washington State should not list any conviction for which the date of conviction or prison release, whichever is more recent, is more than seven years old.)
  Yes   No  
If yes, please explain.
(Conviction of a crime is not an automatic bar from employment. Factors such as the nature and gravity or the crime, the length of time that has passed since the conviction and/or completion of any sentence, and the nature of the job for which you have applied will be considered.)

Are you able to perform the primary duties of the job as outlined in the newspaper advertisement, posting, job description, announcement, job line, ect., with or without reasonable accommodation?

 

 Yes   No  
If no, please explain.
Do you have any employment restrictions resulting from a non-compete or confidentiality agreement?
 Yes     No  

PLEASE USE THE SPACE BELOW TO PROVIDE ANY ADDITIONAL INFORMATION
   (For example, specific skills, additional employers, periods of time not worked, ect.)

PLEASE READ VERY CAREFULLY BEFORE SIGNING.

I certify that I have answered the above questions truthfully and have not withheld any information relative to my application. I understand that any falsification, misrepresentation, or omission, as well as any misleading statements or omissions of the application information, attachments, and supporting documents generally will result in denial of employment or immediate termination, if discovered after hire.

I understand that any questions regarding this statement should be directed to Acumentra Healths human resources manager before I sign below. I understand that this application will be given every consideration, but its receipt does not imply that I will be employed.

It is the policy of Acumentra Health to afford equal opportunity to all employees and applicants without regard to race, age, religion, color, sex, national origin, physical or mental disability, marital or veteran status, sexual orientation, or any other classification protected by federal, state or local law.
I authorize Acumentra Health, or its third party, to conduct any necessary investigation concerning my employment, employment practices and behavior, current and past.
I authorize Acumentra Health to investigate whether I have a criminal record of convictions, and, if so, the nature of such convictions and all the surrounding circumstances of the conviction. Acumentra Health has advised me that any criminal background check will focus on convictions, and that a criminal record will not necessarily disqualify me from employment.

If hired, I agree to abide by the rules and policies of Acumentra Health. I understand that my employment and compensation can be terminated at any time, with or without cause, and with or without notice, at the option of Acumentra Health or myself. I understand that the president is the only person who will ever have the authority to create any other terms of employment and/or to enter into any employment contract and that all such contracts must be in writing and signed by both parties. However, I also understand that unless otherwise stated in an employment contract, the company may change, withdraw and interpret other policies (including wages, hours, and working conditions) as it deems appropriate.

I understand and acknowledge that I may be required to submit to a physical examination, including drug testing. Additionally, I hereby authorize the release of the results of such an examination to Acumentra Health for use in evaluating my suitability for employment. Further, I release the examining facility and Acumentra Health from any and all liability, and from any damage that may result from the release of such information.

I acknowledge reading and understanding the foregoing statements.

Signature:   Date:
 

VOLUNTARY SELF-IDENTIRICATION
Confidential -- For Statistical Use Only

Acumentra Health is an Equal Opportunity Employer and does not discriminate on the basis of race, age, religion, color, sex, national origin, physical or mental disability, marital or veteran status, sexual orientation, or any other classification protected by federal, state or local law. The information below will be used only in compilation of data for Affirmative Action reporting.
Date:

Position applying for:

Gender:
Male:     Female:

Race:
  White (not of Hispanic origin)                              Black
  American Indian                                                  Aisan/Pacific Islander
  Hispanic

Veteran status:                                                                  
  Veteran                                                              Vietnam-era Veteran
  Disabled Veteran                                                Not aplicable
  
Disabled:      Yes            No

Please identify where you learned about this employment opportunity with Acumentra Health:

  State Employment Office                                    Referred by Acumentra Health employee
  Employment agency                                           School placement center
  Temporary agency                                             Walk-in
  Oregonian advertisement
Other Newspaper (Please specify)  
Other (Please specify)    

Attach Resume and Submit Application

Please submit your resume by clicking on the "Browse" button below. Locate your resume file and click "Open". Once you have selected your resume and completed the application, click the "Submit Application" button. If you choose not to submit a resume, simply click the "Submit Application" button.

                             
Note: Please incorporate your first and last name in the file name of you resume document. Example "ResumeBill_Smith.doc"