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Thank you for applying for a position at Southwest Healthcare Services. We are glad you are interested in joining our team of healthcare professionals.

Please note many of the entries are required fields. If you are unable to complete any of the required fields, please signify by typing N/A.

Contact Information
If you are under 18 and it is required, can you furnish a work permit?
Have you ever been employed here before?
Have you ever held a professional License or certification in this state or any other state before?
Are you legally eligible for employment in this country?
Type of employment desired
Are you able to meet the attendance requirements of the position?
Employment History

Provide the following information of you past three (3) employeers, assignments or volunteer activities, starting with the most recent.

May we contact for reference?

May we contact for reference?

May we contact for reference?

Skills and Qualifications
Educational Background
Name/ City/ State
Did you graduate?

Name/ City/ State
Did you graduate?

Provide three (3) references.

Application Statement

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (1) cancel further consideration of this application; or (2) immediately discharge me from the employer's service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professions), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the  accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, adhering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application remains current for 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's administrator.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

Typed name is an official signature

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