Employment Application


Applicant Information 

 

Full Name:   

Date:

Phone:  

Date Available:

Social Security No.:  

Desired Salary:  

Position Applied for:  

Are you a citizen of the United States?

Yes or No   

If no are you authorized to work in the U.S? 

 Yes or No   

Have you ever worked for this company? 

Yes or No   

If yes when? 

Have you ever been convicted of a felony? 

Yes  or No 

If yes, explain:   

 

 

Education

 

 

High School:  

Address:  

From-To:  

Did you graduate?

Yes or No  

Diploma:  

College:  

Address:  

From-To:   

Did you graduate?

Yes  or No  

Degree:   

 

 

References 

 

 

Please list three professional references. 

 

Full name:  

Relationship:  

Company: 

Phone:

Address: 

 

Full name:  

Relationship:  

Company:  

Phone:  

Address:  

 

 

Full name:   

Relationship:  

Company: 

Phone: 

Address: 

 

Previous Employment 

Company:   

Phone:   

Address:   

Supervisor:   

Job Title:   

Starting Salary:   

Ending Salary:    

Responsibilities:   

From-To:   

Reason For Leaving:   

May we contact your previous supervisor for a reference? 

Yes or No

 

Company:   

Phone:   

Address:   

Supervisor:   

Job Title:   

Starting Salary:   

Ending Salary:   

Responsibilities:   

From-To:   

Reason For Leaving:   

May we contact your previous supervisor for a reference? 

Yes  or No   

 

Military Service: 

Branch:   

From-To:   

Rank at Discharge:   

Type of Discharge:  

If other than honorable, explain:   

 

Disclaimer and Signature: 

I certify that my answers are true and complete to the best of my knowledge. 

If this application leads to employment, I understand that false or misleading information on my application or interview may result in my release. 

Signature: 

 

The Cure IV Currently offers house call services for appointment times starting between 6AM 10:30PM. 

Indicate your ON CALL availability for work (Please Circle & Fill in Hours): 

 

Monday, AM/PM:   

Tuesday, AM/PM: 

Wednesday, AM/PM:   

Thursday, AM/PM:   

Friday, AM/PM:

Saturday, AM/PM:   

Sunday, AM/PM:   

 

How many hours total on average per week can you commit to On Call?   

How many house calls a week can you commit to doing?   

The Cure IV  offers services in the greater Los Angeles and San Francisco area from Malibu down to Long Beach inland to Azusa and up to Lakeview Terrace and Northridge and all cities encompassed within. 

How many miles are you willing to drive to your house calls (one way)?  

How many IVs do you start per month? 

How many IV starts are missed on first attempt per month? 

If you cannot start an IV after a 2nd attempt what do you do? 

 

 

 

 

 

 

Leave this empty:

Signature Certificate
Document name: Employment Application
Unique Document ID: aa6a9440fb485995a98a17df33596f2017186222
Timestamp Audit
November 2, 2018 10:43 am PSTEmployment Application Uploaded by Lindsay S - [email protected] IP 76.81.94.114, 10.3.0.88
January 3, 2019 10:55 am PST Document owner [email protected] has handed over this document to [email protected] 2019-01-03 10:55:25 - 76.81.94.114, 10.3.0.88