Apply Now

Employment Applications Fields marked with an * are required

EMPLOYMENT APPLICATION

GMHS is an equal opportunity employer, and does not discriminate against any individual in any phase of employment in accordance with the requirements of local, state, and federal law. Application must be submitted with two passport pictures.

PERSONAL INFORMATION

NAME (Last, First, Middle):

DATE OF BIRTH:

DATE:

HOME PHONE:

CELL PHONE:

EMAIL:

ADDRESS (Street, City, State, Zip):

SOCIAL SECURITY #:

ALIEN ID:

AUTOMOBILE AVAILABILITY:

YES NO

DRIVER'S LICENSE:

YES NO

DRIVER?S LICENSE #:

POSITION DESIRED:

START DATE:

PREFERRED DAYS:

Mon.

Tue.

Wed.

Thu.

Fri.

Sat.

Sun.

PREFERRED SHIFTS:

Morn.

After.

Eve.

EDUCATION

HIGH SCHOOL:

CITY & STATE

YRS

DEGREE

COLLEGE:

CITY & STATE

YRS

DEGREE

NURSING SCHOOL:

CITY & STATE

YRS

DEGREE

SPECIAL TRAINING:

CITY & STATE

YRS

DEGREE

EMERGENCY CONTACT

PRIMARY CONTACT NAME:

PHONE:

RELATION:

SECONDARY CONTACT NAME:

PHONE:

RELATION:

WORK HISTORY

Current Employer:

PHONE:

Address:

Dates of Employment:

Position:

Salary:

Supervisor:

Title:

Reason for Leaving:

Add new row

LICENSES AND/OR CERTIFICATIONS

DO YOU HAVE A CURRENT LICENSE OR CERTIFICATION

YES NO

EXPIRATION DATE:

LICENSE NUMBER:

LPN

EXPIRATION DATE:

LICENSE NUMBER:

CNA/GNA/ HHA

EXPIRATION DATE:

LICENSE NUMBER:

CMA

EXPIRATION DATE:

LICENSE NUMBER:

CPR:

YES NO

ISSUE DATE:

EXPIRATION DATE:

FIRST AID:

YES NO

ISSUE DATE:

EXPIRATION DATE:

CRIMINAL BACKGROUND CHECK:

YES NO

WHICH LEVEL?

STATE

FEDERAL

ISSUE DATE:

GENERAL

List any special skills you may have (e.g. multi-lingua, sign language, other medical expertise etc.) or any additional information which you feel will be helpful in evaluating your qualifications for employment.

I authorize the employers, organizations, and persons stated on this application to give GMHS (including all related entities) any and all information (except information which cannot be obtained as a matter of law) and records concerning my previous employment and education, and I release said employers, organizations or persons from all claims and damages arising out of the provision of this information and/or records to GMHS.

I acknowledge that, if hired, my employment will be at will and therefore can be terminated with or without cause, and with or without notice, at any time, at the option of either GMHS or myself. I also understand that GMHS at its sole discretion, may alter, amend, or eliminate its existing employment policies, procedures, practices, compensation systems and other privileges and benefits at any time, with or without cause and/or notice (except where notice is required by law).

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Applicants Signature:

Date

Your information will be encrypted.