Position Applying For
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First Name (*)
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Middle Initial
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Last Name (*)
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Street Address (*)
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City (*)
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State (*)
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Postal Code (*)
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Social Security Number (*)
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Home Phone (*)
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Work Phone
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Other Phone
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Email Address (*)
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Date Of Birth (*)
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Are you eligible to work in the United States? (*)
Select One Yes No
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If required for position, do you have a valid driver’s license? (*)
Select one Yes No
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If YES, State of issuance
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license #
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Expiration date
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How did you learn about this employment opportunity at Trilogy Health Care? (*)
Job Bulletin (Posting) Walk-in Ad in newspaper Ad in Magazine Website Dept. Of Labor Referral by Employee Other
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Education
Name of High School
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High School City
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High School State
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Did you graduate?
Select One Yes No
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Date of Graduation
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GED
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GED City
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GED State
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Other School
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Other School City
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Other School State
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Did you Graduate?
Select One Yes No
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If yes, when?
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College
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College City
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College State
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Did you graduate?
Select One Yes No
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If yes, when?
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Other credentials/ licenses/ professional affiliations, etc., which are relevant to the job(s) for which you are applying.
Credentials
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SKILLS: Please list technical skills, clerical skills, trade skills, etc., relevant to this position. Include relevant computer systems and software packages of which you have a working knowledge, and note your level of proficiency (basic, intermediate, expert)
Skills
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WORK EXPERIENCE -Please detail your entire work history. Begin with your current or most recent employer. If you held multiple positions with the same organization, detail each position separately. Attach additional sheets if necessary. Omission of prior employment may be considered falsification of information. Please explain any gaps in employment. Include full-time military or volunteer commitments. PLEASE DO NOT complete this information with the notation “See Resume.”
PLEASE NOTE: Trilogy Health Care reserves the right to contact all current and former employers for reference information.
Employer Name
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Employer Address
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Employer City
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Employer State
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Employer 1 Zip
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Dates Employed From
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Date Employed to
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Your Title
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Starting Salary
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Ending Salary
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Supervisor's Name
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Supervisor's Phone
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Primary Duties
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Reason For Leaving
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3 References (Names,Address,Phone)
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PLEASE READ CAREFULLY AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION.
I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date. I authorize Trilogy Health Care to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. If requested, I agree to submit to a physical exam, criminal and credit background investigation, and/or screening for illegal substances upon conditional offer of employment. I understand that this document is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract for continued guaranteed employment. I understand that staff employees of Trilogy Health Care serve at-will, and the employment relationship may be terminated at any time by either party, or any or no reason, other than a reason prohibited by law. If employed, I will be required to furnish proof of eligibility to work in the United States, to file a State security questionnaire and State loyalty oath, and to comply with company and departmental regulations. I understand that if employed on a temporary basis, I would be paid for hours worked only, and would be ineligible for benefits including paid time off. If employed on a regular, benefits-eligible basis, I understand that I would be required to make mandatory contributions to the {Insert Name of Company} Retirement System or to an optional retirement program, if applicable. I understand that any benefits I receive may be subject to change or discontinuation at any time without prior notice. I understand that the first SIX MONTHS of regular employment represent a provisional period, during which I would not be eligible to apply for transfer or promotion and during which I may be terminated without right of appeal.
Signature (please type your name if you understand the previous statement)
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If you have a resume please upload here.
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