Employment Application

If you are human, leave this field blank.

APPLICANT INFORMATION

Name *

First

Last *

Last

Email *

Phone *

Address *

Address Line 2

City *

State *

Zip *

Country *

Last Four Digits of Social Security Number *

Position applied for *

Desired Salary *

How were you referred?

Are you a citizen of the United States? *

Yes

If no, are you authorized to work in the US?

Yes

Are you at least 18 years of age? *

Yes

Have you ever been convicted of a felony? *

Yes

If yes, please explain

EDUCATION

High School

Address

Did you graduate?

Yes

Degree

College

Address

Did you graduate?

Yes

Degree

Other Education Information

REFERENCES

Please list three professional references. Do not list friends or family members.

Full Name

Relationship

Company

Email Address

Phone Number

Full Name

Relationship

Company

Email Address

Phone Number

Full Name

Relationship

Company

Email Address

Phone Number

PREVIOUS EMPLOYMENT

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

Dates

From

Reason for leaving

May we contact your previous supervisor for a reference?

Yes

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

Dates

From

Reason for leaving

May we contact your previous supervisor for a reference?

Yes

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

Dates

From

Date

Reason for leaving

May we contact your previous supervisor for a reference?

Yes

MILITARY SERVICE

Branch

Dates

From

Rank at Discharge

Type of Discharge

APPLICANT CERTIFICATION

I hereby certify that the information provided in this application is true. I understand that providing false information or omitting responsive information may disqualify me from further consideration for employment and may result in loss of employment if discovered at a later date. I authorize Odyssey Health Systems, LLC to consider and use the information to verify my qualifications for employment. I also understand that if hired, I will be an at-will employee and shall not be guaranteed employment for any definite period.

Signature

Date

EQUAL OPPORTUNITY EMPLOYER

This facility is an equal opportunity employer. No question is asked for the purpose of limiting or excluding any applicant from consideration for employment due to his/her age, race, color, religion, sex, disability, national origin or any other protected characteristics.

Attach Resume *

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ODYSSEY HEALTH SYSTEMS, LLC

Best Practices

Employment Application

APPLICANT INFORMATION

EDUCATION

REFERENCES

PREVIOUS EMPLOYMENT

MILITARY SERVICE

APPLICANT CERTIFICATION

EQUAL OPPORTUNITY EMPLOYER

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