* = Required Information |
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How did you hear about DAISY Health Services, Inc.? |
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DAISY Health Services, Inc. is an Equal Opportunity Employer. We hire and promote without regard to race, color, sex, religion, workers' compensation history, marital or veteran status, age, sexual orientation, mental or physical disability, or any other reason prohibited by law. Please read carefully and clearly print your information below. |
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APPLICANT INFORMATION |
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State |
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Are you 18 years of age or older? |
YesNo |
Are You a U.S. Citizen or National? |
YesNo |
If no, are you legally eligible to work in the U.S.? |
YesNo |
If yes, can you submit verification of eligibility? |
YesNo |
Can you perform the essential functions of the job for which you are applying for with or without reasonable accommodations? |
YesNo |
If no, describe the essential functions that you cannot perform |
Have you ever been convicted of a felony? (Conviction will not necessarily disqualify an applicant for employment) |
YesNo |
If yes, please give particulars |
DESIRED POSITION |
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AVAILABILITY |
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Are there any hours, days or shifts you cannot or will not work? |
YesNo |
If yes, please list those hours, days or shifts |
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EDUCATION |
Do you have a High School Diploma or Equivalent? |
YesNo |
College/University |
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Other training/education - Name and Location |
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EMPLOYMENT HISTORY |
If you were employed under a different name, please give the name used. |
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Most Recent Employer |
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Are you currently working for this employer? |
YesNo |
May we contact this employer? |
YesNo |
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Reason for leaving * |
Description of duties * |
Previous Employer |
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Are you currently working for this employer? |
YesNo |
May we contact this employer? |
YesNo |
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Reason for leaving |
Description of duties |
Previous Employer |
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Are you currently working for this employer? |
YesNo |
May we contact this employer? |
YesNo |
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Reason for leaving |
Description of duties |
REFERENCES |
Please list three people that are NOT related to you that we may contact. (All three should be business related references) |
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Name: |
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Company: |
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Telephone: |
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Work Relationship: |
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Name: |
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Company: |
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Work Relationship: |
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Name: |
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Work Relationship: |
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EQUAL OPPORTUNITY EMPLOYER |
DAISY Health Services, Inc. is an equal opportunity employer and we adhere to State and Federal regulations regarding affirmative action. We make every effort to ensure that all decisions regarding our applicants and employees are free of any illegal consideration of a person's ethnic background or protected class status. Careful analysis of our recruitment and selection practices is an important part of our on-going effort to ensure that everyone has equal access to our employment opportunities. By supplying the information below, you help us get a more complete understanding of our applicants and the fairness of or selection methods. Please keep in mind that this is optional. You are not obligated to complete this form. If you choose not to participate, it will NOT impact your application negatively. |
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EMPLOYEE INFORMATION |
Name:* |
Telephone:* |
Contact Number:* |
Position Applied For:* |
Date:* |
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ETHNICITY(Check One)* |
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Gender:* |
MaleFemale |
Disability: |
YesNo |
Veteran: |
VietnamVetSpecialDisabledVetOtherVetDischarged |
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* Security Code |
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