Employment Form - Haxtun Health

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Contact Information

Name*

First Middle Last

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Which Job opening(s) are you applying for?*

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Would you prefer to work:*

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Other (List Below)

Willing to relocate

Work Experience

Job Title*

Company / Organization*

Location*

From*

To

Job Duties

Job Title*

Company / Organization*

Location*

From*

To

Job Duties

Job Title*

Company / Organization*

Location*

From*

To

Job Duties

Education

Name and Location of School*

Level of Education / Degree*

Major

Minor

From*

To

Or expected graduation date.

Description

Skills

Please indicate other skills related to the position you are seeking:

References

List three individuals, not relatives, who are familiar with your work-related skills.

Reference 1 Name and Phone Number*

Reference 2 Name and Phone Number*

Reference 3 Name and Phone Number*

Behaviors

What is your work style?*

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Motivation

Motivations*

What gets you out of bed in the morning?
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Licenses and Certifications

License / Certification Type (if applicable)

Date Achieved

Renewal Date

Links

Link Title

Support Document (Optional)

Max. file size: 6 MB.

Website

Please use a full URL, e.g. https://example.com

Documents

Support Document (Optional)

Max. file size: 6 MB.

Support Document (Optional)

Max. file size: 6 MB.

Questions

How did you hear about this opportunity?*

Were you referred by a current employee?

Yes
No

If Yes Employee Name?

Date available to start?

Why do you believe that you are the best candidate for this position?*

Why are you interested in this role?*

Additional Licenses & Certifications

Are you authorized to work in the U.S.?*

Yes
No

Have you ever been "sanctioned" or lost your ability to participate, as a provider or a care giver, in Medicare or any other federal program?*

Yes
No

Have you served in the United States Military?*

Yes
No

Are you under 18 years of age?*

Yes
No

(If no, employment is subject to minimum legal age requirements)

Do you have any relatives who are currently employed by Haxtun Health?*

Have you previously worked for Haxtun Health?*

EEOC - Voluntary Self-Identification Survey

This employer is required to notify all applicants of their rights pursuant to federal labor laws. For further information, please review this notice from the Department of Labor: "EEO is the Law" poster. You may have additional rights pursuant to recent amendments to federal labor laws. Please review these protections from the EEO is the Law Supplement. This employer is subject to certain nondiscrimination and/or affirmative action record keeping and reporting requirements which require the employer to invite applicants to voluntarily self-identify their race/ethnicity and gender.

Gender*

Ethnic Origin*

Veteran Status

We ask all candidates to provide the information listed below. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information you provide will be kept confidential and may only be used in accordance with applicable federal, state, and local laws and regulations.

Are you a protected veteran?*

Voluntary Self-Identification of Disability

We ask all candidates to provide the information listed below. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information you provide will be kept confidential and may only be used in accordance with applicable federal, state, and local laws and regulations.

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