PERSONAL INFORMATION
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Name (*)
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Social Sec. No. (*)
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Address (*)
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Home Phone
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Cell Phone
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Email (*)
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Marital Status
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Ethnicity
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Religion
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Languages Spoken
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Emergency Contact
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Phone No
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Relationship
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JOB RELATED
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Position Applying For (*)
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Days Available
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Are you willing to travel
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Same Day Assignments
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Can you work in an environment with
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Do you have use of automobile and current auto insurance?
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Are you on Bus Line?
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What Salary is Required
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Have you ever been convicted of a felony?
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If convicted of a felony, explain.
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EDUCATION HISTORY
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Last grade completed ( High School ) (*)
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Name of High School (*)
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Last Year completed ( College or Trade School)
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State (*)
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Name of College or Trade School
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State
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State any experience, special skill, or qualification, which you feel qualifies you to work for APREMIUM HEALTHCARE SOLUTION, LLC.
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REFERENCES (List three (3) personal and/or professional references)
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Reference 01
Reference
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Address
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Relationship
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Phone No
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Year (s) Known
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Reference 02
Reference
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Address
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Relationship
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Phone No
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Year (s) Known
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Reference 03
Reference
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Address
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Relationship
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Phone No
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Year (s) Known
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EMPLOYMENT HISTORY (List your last five years employment history below starting with the present job)
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Employer
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Address
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Dates Employed ------------------------------
From (Month/Year)
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To (Month/Year)
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Final Wage
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Please, explain any period you where not employed? ------------------------------
Month
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Reason
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Immediate Supervisor
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Company Phone#
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Job Title
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Duties/Responsibilities
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Seperation was
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Reason
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Employer
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Address
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Dates Employed ------------------------------
From (Month/Year)
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To (Month/Year)
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Final Wage
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Please, explain any period you where not employed? ------------------------------
Month
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Reason
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Immediate Supervisor
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Company Phone#
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Job Title
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Duties/Responsibilities
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Seperation was
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Reason
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Employer
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Address
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Dates Employed ------------------------------
From (Month/Year)
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To (Month/Year)
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Final Wage
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Please, explain any period you where not employed? ------------------------------
Month
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Reason
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Immediate Supervisor
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Company Phone#
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Job Title
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Duties/Responsibilities
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Seperation was
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Reason
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Employer
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Address
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Dates Employed ------------------------------
From (Month/Year)
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To (Month/Year)
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Final Wage
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Please, explain any period you where not employed? ------------------------------
Month
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Reason
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Immediate Supervisor
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Company Phone#
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Job Title
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Duties/Responsibilities
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Seperation was
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Reason
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.
As an applicant for employment with APREMIUM HEALTHCARE SOLUTION, LLC, I understand the following:
• I certify that the facts contained in this application are true and complete to the best of my knowledge and understand they are subject to verification. If employed; falsified statements on this application shall be grounds for dismissal.
• I understand that under conditional offer of employment I am required to submit to pre-employment drug and alcohol screening. The results of such testing may be grounds for withdrawing the offer or employment.
• I must meet the employability requirements of Federal Immigration Law and submit appropriate documentation to satisfy the requirements for completing INS Form I-9.
• If my application for employment is accepted, the effective date of my employment may be time I actually begin to work. If I accept the employment, I agree to comply with and be bound by the safety and health rules and regulations and rules of conduct of APREMIUM HEALTHCARE SOLUTION, LLC. altogether with obligations set forth in the Company policies.
Will you authorize APREMIUM HEALTHCARE SOLUTION, LLC, to contact each of your previous employers and references? If No state which of your previous employers you do not want us to contact, give the reason why?
Employer
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Reason
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