Job Opportunities

Please complete the form below and submit. One of our administrators will get back with you as soon as possible. Thank you.

Application for Employment

An Equal Opportunity/Affirmative Action Employer

(Application for Employment) Please Read Carefully.

You are not required to answer qucstion(s) which you feel may violate federal, state and/or local laws or which you feel is not related to the position which you are applying.

Date of Application:

Month

Day

Year

Date of Birth:

Month

Day

Year

SS #:

First Name:

Last Name:

Email:

Phone:

Home Address:

Country/Region

Address

City

Zip / Postal code

Job Interest

Position Applying For:

Salary Desired Per Hour:

Are you authorized to work in the USA?

Yes

No

By Checking these boxes you acknowledge the following:

I understand that an offer of employment and my continued employment with CHPCS are contingent upon satisfactory proof of my authorization to work in the United States as well as successful completion of a background investigation including criminal history and identity check.

I understand that CHPCS is an At-will employer (is a term used in U.S. labor law for contractual relationships in which an employee can be dismissed by an employer for any reason).

Are you 18 years of age or older?

Yes

No

State name(s) of any friends or relatives working for the facility:

Have you ever been employed by any organization affiliated with CHPCS?

Yes

No

If so, which one and dates:

How were you referred to this property?

Do you have reliable transportation to and from work?

Yes

No

Please list any specific skills that would contribute to the position you arc applying for:

Please upload certifications and licenses you make hold:

Why do you want to Work for CHPCS?

Waiver for Criminal History

By Checking this box and providing your signature underneath, you acknowledge the following:

I understand that if hired until my background check, Motor Vehicle record and TB skin test is cleared I am working under the conditions that any negative items found on any of these will dismiss me as a temporary employee. Until the results are back I am considered a Temporary worker.

Signature of the pending employee:

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You can also upload a clear photo of your signature.

I understand that if hired at some point in the job assignment the following may be required: If required, would you be willing to work. Check All That Apply:

Shift Work

Rotational Work Schedule

Work schedule other than Monday thru Friday

Overtime

When will you be available to begin work?

Month

Day

Year

V.'hat type of work are you applying for?

Full Time

Part Time

Temporary

Education and Training

High School Graduate Or General Education (GED) Test Passed?

Yes

No

If no, list the highest grade completed:

Please list the Name, Dates Attended, Credit Hours, Degree and Year, and Major or Subject while in College, Business School, Military.(Start with most recent first)

Work Experience

Employer:

Date Employed:

Month

Day

Year

Date Left:

Month

Day

Year

Employer Number:

Employer Address:

Job Title:

Number Employees Supervised:

Specific Duties

Hours Per Week:

Last Salary:

Emergency Contact Information

Emergency Contact Name:

Emergency Contact Address:

Country/Region

Address

City

Zip / Postal code

Emergency Contact Daytime Phone:

Emergency Contact Relationship:

INFORMATION TO THE APPLICANT

As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references.

If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the United States, have a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms. I understand and

agree to the information shown above.

Signature of Applicant:

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You can also upload a clear photo of your signature.

Date of Application:

Month

Day

Year