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Your Name
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Email
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Best Phone to Contact You
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Position/Title You are Pursuing
Highest Level Completed
High School Name/ Location/ Year Began & Graduated
For Example:
ABC High School
1234 School Drive Durham, NC
2000 - 2004
College Name/ Location/ Year Began & Graduated/ Degree Acquired
Graduate School/ Location/ Year Began & Graduated/ Degree Acquired
Vocational/ Technical Name/ Location/ Year Began & Graduated/ Degree Acquired
List courses, workshops, trainings, or rotations you have had that are related to the position you are applying for
Skills & Experiences
Please check all that apply
How many words per minute can you type?
How many words per minute can you write?
Do you have a driver's license?
Yes
No
Do you have a car for use at work?
Yes
No
List fields of work for which you have been registered, licensed, or certified
Example:
Certification Name
State Registered In
Registration/ Certification Number
Expiration Date
List professional memberships and industry-related organizations you participate in
Number of People You Have Supervised in these Roles
Please Check the Roles that You have Supervisory or Managerial Experience In
Employer/ Company Name & Type of Organization
Company Phone
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Company Address
Address 1
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Supervisor Name
First Name
Last Name
May we contact your supervisor?
Yes
No
Please wait until I am a finalist
Employment Status
Full Time
Part-Time
Number of Years and Months You were Full Time and/or Part-Time
Job Duties
Amount of People You Supervised
Starting Salary
Ending Salary
Date You Left Company
Reason for Leaving
#2. Employer/ Company Name & Type of Organization
Company Phone
(###)
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Company Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Supervisor Name
First Name
Last Name
May we contact your supervisor?
Yes
No
Please wait until I am a finalist
Employment Status
Full Time
Part-Time
Number of Years and Months You were Full Time and/or Part-Time
Job Duties
Amount of People Supervised
Starting Salary
Ending Salary
Date You Left the Company
Reason for Leaving
#3. Employer/ Company Name & Type of Organization
Company Phone
(###)
###
####
Company Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Supervisor Name
First Name
Last Name
May we contact your supervisor?
Yes
No
Please wait until I am a finalist
Employment Status
Full Time
Part-Time
Number of Years and Months You were Full Time and/or Part-Time
Job Duties
Amount of People You Supervised
Starting Salary
Ending Salary
Date You Left the Company
Reason for Leaving
#4. Employer/ Company Name & Type of Organization
Company Phone
(###)
###
####
Company Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Supervisor Name
First Name
Last Name
May we contact your supervisor?
Yes
No
Please wait until I am a finalist
Employment Status
Full Time
Part-Time
Number of Years and Months You were Full Time and/or Part-Time
Job Duties
Amount of People You Supervised
Starting Salary
Ending Salary
Date You Left Company
Reason for Leaving
#5. Employer/ Company Name & Type of Organization
Company Phone
(###)
###
####
Company Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Supervisor Name
First Name
Last Name
May we contact your supervisor?
Yes
No
Please wait until I am a finalist
Employment Status
Full Time
Part-Time
Number of Years and Months You were Full Time and/or Part-Time
Job Duties
Amount of People You Supervised
Starting Salary
Ending Salary
Date You Left Company
Reason for Leaving
Do you now work for Perseverance Integrated Healthcare, LLC?
Yes
No
Are you related by blood or marriage to any person now working at Perseverance Integrated Healthcare, LLC? (If yes, please give name, relationship to you, and the department where employed)
Have you ever worked under any other name? (If yes, please provide that name)
Please check types of work you will accept
If yes, please explain.
Please note that existence of criminal charges does not automatically eliminate you from employment considerations.
Reference #1 Name
First Name
Last Name
Years Known
Reference Profession or Organizational Position
Home or Business Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Best Contact Phone Number
(###)
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Reference #2 Name
First Name
Last Name
Years Known
Reference Profession or Organizational Position
Home or Business Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Best Contact Phone Number
(###)
###
####
Reference #3 Name
First Name
Last Name
Years Known
Reference Profession or Organizational Position
Home or Business Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Best Contact Phone Number
(###)
###
####
I certify, to the best of my knowledge and belief, that the statements given above truly represent my background and experience. I understand that if I have knowingly misrepresented, omitted, or falsified any of the application information. I will be disqualified for employment consideration or dismissed from employment with the Perseverance Integrated Healthcare, LLC. Further, I understand that as a condition of employment, I may be required to undergo testing for controllable substances. In addition, I hereby authorize my current and former employers (including the US Government or US Military), personal references, registration and licensing boards, and educational institutions listed on my application for employment, to provide Perseverance Integrated Healthcare, LLC. with any job-related information requested. I also permit Perseverance Integrated Healthcare, LLC. to conduct police and court records investigation of my background if relevant to the job for which I am applying. Notwithstanding any provisions of Federal or State Law, I expressly waive any right I may have to review confidential material or information received by Perseverance Integrated Healthcare, LLC from a previous employer or educational institution. Finally, I attest, under penalty or perjury, that I am legally authorized to work in the United States, and that, if I am a male between the ages of 18-26 registered for selective services.
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