APPLICATION FOR EMPLOYMENT

 

Jamhuri Healthcare Services Inc, is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status.
PERSONAL:

Name ________________________________________ Date __________            Last                         First                           Middle Address _______________________________________________________                Number & Street            City                 State                 Zip Code Position Sought ____________________   ___ Full Time ___ Part Time Date Available ________    Salary Desired ________    Phone # _________

Email Address ________ Social Security Number ___________

Are you over 18 years old? __ Yes __ No Are you legally eligible for employment in the United States? __ Yes __ No (If offered employment, you will be required to provide documentation to verify eligibility.)

 

EDUCATION:

Please indicate education or training which you believe qualifies you for the position you are seeking. High School: No. of Yrs Completed (circle one) 1   2   3   4 Diploma: __ Yes __ No     G.E.D.: __ Yes __ No       School(s) ____________________ City/State ____________________ College and/or Vocational School: Number of Years Completed (circle one) 1   2   3   4       School(s) ____________________ City/State ____________________       Major ____________________ Degrees Earned ____________________ Other Training or Degrees:       School(s) ____________________ City/State ____________________       Course _______________ Degree or Certificate Earned ______________

 

 

PROFESSIONAL LICENSE OR MEMBERSHIP:

Type of License(s) Held__________________________________________ State of [State Name] License Number ___________________________________ License Expiration Date ___________________________________________ Other Professional Memberships ____________________________________

(You need not disclose membership in professional organizations that may reveal information regarding race, color, creed, sex, religion, national origin, ancestry, age, disability, marital status, veteran status or any other protected status.)

 

This application for employment is good for 90 days only. Consideration for employment after 30 days requires a new application.

 

SKILLS : Office:    Typing _____ wpm.       __ Microsoft Word       __ Excel    __ Powerpoint

Other Software Skills ___________________________________ Have you ever been employed by Jamhuri Healthcare Services Inc ?   __ Yes   __ No If so, please state facility name and location and dates of employment ______________________________

RECORD OF CONVICTION :

During the last ten years, have you ever been convicted of a crime other than minor traffic offense?           __ Yes __ No If yes, explain: _________________________________________________ (A conviction will not necessarily automatically disqualify you for employment. Rather, such factors as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered).

 

EMPLOYMENT:

List last employer first, including U.S. Military Service. May we contact your present employer?    ____ Yes    ____ No If any employment was under a different name, indicate name _____________ Employer ____________________ Address _________________________ Telephone _______________ Position _______________ Dates of Employment: From _____ To _____                                            Mo/Yr     Mo/Yr Salary __________ Supervisor ________________ Department __________ Duties _________________________________ FT __ PT __ No. of Hrs.___ Reason for Leaving ______________________________________________ Employer ____________________ Address _________________________ Telephone _______________ Position _______________ Dates of Employment: From _____ To _____                                            Mo/Yr     Mo/Yr Salary __________ Supervisor _________________ Department __________ Duties _________________________________ FT __ PT __ No. of Hrs.___ Reason for Leaving ______________________________________________

 

 

Employer ____________________ Address _________________________ Telephone _______________ Position _______________ Dates of Employment: From _____ To _____                                            Mo/Yr     Mo/Yr Salary __________ Supervisor _________________ Department __________ Duties _________________________________ FT __ PT __ No. of Hrs.___ Reason for Leaving ______________________________________________ Employer ____________________ Address _________________________ Telephone _______________ Position _______________ Dates of Employment: From _____ To _____                                            Mo/Yr     Mo/Yr Salary __________ Supervisor _________________ Department __________ Duties _________________________________ FT __ PT __ No. of Hrs.___ Reason for Leaving ______________________________________________

 

If you wish to describe additional work experience, attach the above information for each position on a separate piece of paper. Explain any gaps in work history: ___________________________________ Have you ever been discharged or asked to resign from a job? __Yes __No If yes, explain: ________________________________________________

_____________________________________________________________

Professional Personal
Name   _________

___________ Address ___________________              ___________________ Phone   (_____)_____________

Email       ___________________

Name   ____________________ Address ___________________              ___________________ Phone   (_____)_____________

Email       ___________________

Name   ___________________ Address ___________________              ___________________ Email   ___________________

Phone   (_____)_____________

Name   ____________________ Address ___________________              ____________________ Email   ____________________

Phone   (_____)______________

REFERENCES:

 

 

 

APPLICANT’S CERTIFICATION AND AGREEMENT

 

I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Jamhuri Healthcare services Inc to verify their accuracy and to obtain reference information on my work performance. I hereby release Jamhuri Healthcare Services Inc,from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information.

I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal.

I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of the Employer. However, I further understand that neither the policies, rules, regulations of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either I or the Employer may terminate my employment at any time with or without notice or cause.

Signature of Applicant ________________________ Date: __________

 

Please sign, all the relevant Places and print the whole application.

then mail it to:

Att: HR Department

Jamhuri Healthcare Services Inc

P.O. Box 32381, Pikesville MD 21282