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How did you hear about DAISY Health Services, Inc.?
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School or Organization:
Personal Referral:
Other Source:

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.
 
APPLICANT INFORMATION
State
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
 
AVAILABILITY
  Monday Tuesday Wednesday Thursday Friday Saturday Sunday
 
Begin Time
 
End Time
 
Are there any hours, days or shifts you cannot or will not work? YesNo
If yes, please list those hours, days or shifts
 
EDUCATION
Do you have a High School Diploma or Equivalent? YesNo
College/University
Other training/education - Name and Location
EMPLOYMENT HISTORY
If you were employed under a different name, please give the name used.
 
Most Recent Employer
Are you currently working for this employer? YesNo
May we contact this employer? YesNo
Reason for leaving *
Description of duties *
Previous Employer
Are you currently working for this employer? YesNo
May we contact this employer? YesNo
Reason for leaving
Description of duties
Previous Employer
Are you currently working for this employer? YesNo
May we contact this employer? YesNo
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)
 
Name:
Company:
Telephone:
Work Relationship:
 
Name:
Company:
Telephone:
Work Relationship:
 
Name:
Company:
Telephone:
Work Relationship:
 
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.
 
EMPLOYEE INFORMATION
Name:*
Telephone:*
Contact Number:*
Position Applied For:*
Date:*
 
ETHNICITY(Check One)*
American Indian Alaska Native Caucasian Black
African American Hispanic Latino Asian
Other
Gender:* MaleFemale
Disability: YesNo
Veteran: VietnamVetSpecialDisabledVetOtherVetDischarged

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