Career Application

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Contact/General InformationRequired Field*

Last Name*

First Name*

Middle Initial*

Address*

City*

State*

Zip*

Day Phone #*

Home Phone #*

Cell Phone #*

Email Address*

How often do you check email?*

Position Applying For*

Hourly Wage Expected*

Have you ever been 1) convicted of a crime or 2) are you presently charged with a felony?*

Do you know anyone who works here?*

If so, who?

Have you ever applied or worked at CHCWM before?*

Are you legally able to work in the U.S.?*

Are you 18 or older?*

Are you able to perform the physical demands of the job for which you are applying with or without reasonable accomodation?*

Where did you hear about this job?*

How many days would you prefer per week?*

Time Availability

	Monday	Tuesday	Wednesday	Thursday	Friday
From	*	*	*	*	*
To	*	*	*	*	*

Date available for work - *

Most Recent Jobs (1 Required)

Job Title*

Begin Date*

End Date*

Total years/months service*

Employer*

City*

State*

Hourly rate*

Eligible for rehire?

Hours worked per week

Supervisor*

Supervisor daytime phone*

May we contact?

Reason for leaving*

Duties/Responsibilities*

Job Title

Begin Date

End Date

Total years/months service

Employer

City

State

Hourly rate

Eligible for rehire?

Hours worked per week

Supervisor

Supervisor daytime phone

May we contact?

Reason for leaving

Duties/Responsibilities

Job Title

Begin Date

End Date

Total years/months service

Employer

City

State

Hourly rate

Eligible for rehire?

Hours worked per week

Supervisor

Supervisor daytime phone

May we contact?

Reason for leaving

Duties/Responsibilities

Job Title

Begin Date

End Date

Total years/months service

Employer

City

State

Hourly rate

Eligible for rehire?

Hours worked per week

Supervisor

Supervisor daytime phone

May we contact?

Reason for leaving

Duties/Responsibilities

Job Title

Begin Date

End Date

Total years/months service

Employer

City

State

Hourly rate

Eligible for rehire?

Hours worked per week

Supervisor

Supervisor daytime phone

May we contact?

Reason for leaving

Duties/Responsibilities

Most Recent Schools (1 Required)

Name*

City*

State*

Field of study*

Type of degree*

Name

City

State

Field of study

Type of degree

Name

City

State

Field of study

Type of degree

Professional Certification/Registration/Licenses

Name	Date

Professional References - Must be current or former co-workers or supervisors (3 required)

I give my below listed references permission to disclose, in good faith, information regarding my employment record or professional relationship. I will hold them free of liability for the exchange of this information and any other reasonable and necessary information to CHCWM’s employment process.

Name	May we contact?	ACCURATE Daytime Phone	Relationship	Where did you work with this person?
*	*	*	*	*
*	*	*	*	*
*	*	*	*	*

Other Special Training, Skills, Languages

Resume/Cover Letter (.doc, .docx, .pdf, or .rtf only)

Upload your Cover Letter

Upload your Resume

Electronic Release

The information provided in this Application for Employment is true, correct and complete. If you employ me, any misstatement or omission of fact on this application may result in my dismissal. I understand that acceptance of an offer of employment creates no obligation upon CHCWM to continue to employ me in the future.

Electronic Signature*

Date*