We are An Equal Opportunity Employer

Application For Employment

INSTRUCTIONS: Please furnish all information requested on this form. If you wish to supply additional education or work history information, please email it to smays@pshhc-wa.com. Resume submission to the same address is optional.
Position(s) Applied for Date of Application

Personal Data
Last Name
First Name
Middle Name
Social Security Number

Email Address:


Present Address
Street
City
State
Zip
Phone Number

Permanent Address
Street
City
State
Zip
Phone Number

If you are under 18 years of age, can you provide required proof of eligibility to work? Yes No
Are you a military veteran? (If yes, please list under Work Experience.) Yes No
How did you learn about this position opening? Ad Friend Other
Have you any relatives employed here? Yes No
If yes, please indicate name(s) and in what position.
Have you been previously employed here? Yes No If yes, give dates.
Have you been convicted of an offense or been released from prison within the past ten (10) years? Yes No
If yes, explain fully.

Work Availability
Full-time Part-time On-Call Temporary
If Temporary or On-call, indicate when available.
Indicate shift(s) you will work: 1st shift - days 2nd shift - evenings 3rd shift - nights
Will you rotate shifts? Yes No
Will you work weekends? Yes No
Indicate days you are available for work. Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Job Performance Ability
Given your knowledge, skills, education, and experience, are you able to perform all of the essential functions of the position for which you are applying, with or without reasonable accommodation, as set forth in the job description? Yes No

Education
High School
School Name Location Major Course of Study
Dates Attended Did you Graduate? Yes No

College or Schools after high school (include any job related education or training in military service)
School Name Location Academic Major, Skill or Trade
Dates Attended Did you Graduate? Yes No

School Name Location Academic Major, Skill or Trade
Dates Attended Did you Graduate? Yes No

School Name Location Academic Major, Skill or Trade
Dates Attended Did you Graduate? Yes No

School Name Location Academic Major, Skill or Trade
Dates Attended Did you Graduate? Yes No

Work Experience
List most recent employer first. Include at least past five (5) years, and account for any time gaps in your employment history, including any military service.
Name of employer Address
Dates employed (mo/yr) From To Final Salary $
Name of supervisor Phone # May we contact? Yes No
Your last job title and description
Reason for leaving

Name of employer Address
Dates employed (mo/yr) From To Final Salary $
Name of supervisor Phone # May we contact? Yes No
Your last job title and description
Reason for leaving

Name of employer Address
Dates employed (mo/yr) From To Final Salary $
Name of supervisor Phone # May we contact? Yes No
Your last job title and description
Reason for leaving

Name of employer Address
Dates employed (mo/yr) From To Final Salary $
Name of supervisor Phone # May we contact? Yes No
Your last job title and description
Reason for leaving
Did you work for any of the above employers under a different name? If so, please select which one(s) 1: 2: 3: 4:
Give previous name

Attendance
Do you now have or do you anticipate having any activities, commitments or responsibilities that may prevent you from meeting your work attendance requirements? Yes No
If yes, please explain

Professional Registration/Licensure
Type of Registration or License State
Number Date of Expiration

Type of Registration or License State
Number Date of Expiration
If you do not have a required registration or license, have you applied for one? Yes No
If an examination is required, what date are you scheduled to take the examination?
If not licensed in Washington State, have you applied for reciprocity? Yes No

I certify that the information set forth in this Application for Employment is true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application or failure to furnish all requested information shall be considered sufficient cause for my dismissal.

I understand that my employment shall be contingent upon proof of identity and verification of eligibility for employment in the United States in accordance with the immigration Reform and Control Act of 1986. I further understand that my employment is contingent upon the checking of references furnished by me.

I consent to and authorize this employer and its personnel to request any information concerning my previous employment record as indicated on this Application for Employment. I hereby release all parties and persons connected with any request for information from all claims, liabilities, and damages for whatever reason arising out of furnishing such job related information.
Type your full name to serve as a signature

Employment History Reference Check
Employer #1
Name of Former Employer
Former Employer's Mailing Address
City State Zip

Job title while with former employer:
Dates of employment: from to


Employer #2
Name of Former Employer
Former Employer's Mailing Address
City State Zip

Job title while with former employer:
Dates of employment: from to