WPC[  غU!g]B,%!$)X(^QzvIyV Fv6^RJj%S p6yDd{nPrLNpANV8ǗRX#ec)П!ӯFpeV[yPڷbgbch {k+k,M*ӭLg}Cq].C\][dhkH2|jH > (Yes򀀀No򀀀   (Ifunder18,hireissubjecttoverificationthatyouareofminimumlegalage.)   Ifhired,canyoupresentevidenceofyourU.S.citizenshiporproofofyourlegalright cC  Rtoliveandworkinthiscountry?00;(#.  +Yes򀀀No򀀀 ; Areyouabletoperformtheessentialfunctionsofthejobforwhichyouareapplying?00;(#.xx`Yes򀀀No򀀀 _  Ifno,describethefunctionsthatcannotbeperformed.AV)4dwE4_A  AV) xdAErxA sS AV) xdAEYxA Z:! AV) xdAE@xA A!#  (Note:WecomplywiththeADAandconsiderreasonableaccommodationmeasuresthatmaybe (% necessaryforeligibleapplicants/employeestoperformessentialfunctions.) & Areyouabletoperformallotherdutiesofthejobforwhichyouareapplying?00;(#.XXYYes򀀀No򀀀 D$(  Ifno,describethefunctionsthatcannotbeperformed.AV)ddwEd$A h* AV) xdAE7xA 8, AV) xdAE xA  .  (Note:Hiremaybesubjecttopassingamedicalexamination,andtoskillandagilitytests.) !0 Haveyoueverbeenconvictedofacriminaloffense(felonyorseriousmisdemeanor)?(Convictionsfor J"*2 marijuanarelatedoffensesthataremorethantwoyearsoldneednotbelisted.)00;(#.zzZYes򀀀No򀀀 "# 3  Ifyes,statenatureofthecrime(s),whenandwhereconvictedanddispositionofthecaseAV)DdwE%DA f$F!5 AV) xdAE&xA &"7 AV) xdAE&xA   AV) xdAE'xA '$;  (Note:Noapplicantwillbedeniedemploymentsolelyonthegroundsofconvictionofacriminaloffense. 7)&> Thenatureoftheoffense,thedateoftheoffense,thesurroundingcircumstancesandtherelevanceofthe *&? offensetotheposition(s)appliedformay,however,beconsidered.) *'@ Areyoucurrentlyemployed?00;(#.  %Yes򀀀No򀀀 +, )B Ifso,maywecontactyourcurrentemployer?00;(#.6Yes򀀀No򀀀  o-O*D  Education,TrainingandExperience    *ddd Xdd Xdd X(#(#,dd ,dd ,$$ ,$$ ,$$ +   School  o NameandAddress  o  No.of K+  years #  Completed ' " 'Didyou K+ Graduate? '#" 'Degreeor K+ Diploma !V#" !High g G School )VV V ) )VVg GVV ) )VVg GVV ) )VVg GVV ) 'Vg GVV 'College/   University )VV V ) )VV VV ) )VV VV ) )VV VV ) 'V VV 'Vocational [;  /Business )VV3 V ) )VV[; !VV ) )VV[; "VV ) )VV[; #VV ) +VV[; $VV +Health  % Care +VVV'VV + +VVV (VVV + +VVV )VVV + +VVV *VVV +( +  VVV (Manyofourcustomers(clients)donotspeakEnglish.Doyouspeak,writeorunderstandanyforeign {- languages?00;(#.Yes򀀀No򀀀 sS. Ifyes,whichlanguage(s)?AV)  dwE S A 0  Doyouhaveanyotherexperience,training,qualificationsorskillswhichyoufeelmakeyouespecially 2 suitedforworkatLongValleyHealthCenter?Ifso,pleaseexplain. 3 AV) xdAExA c5 AV) xdAEixA jJ7 AV) xdAEPxA Q19  Answerthefollowingquestionsifyouareapplyingforaprofessionalposition  8;  (Areyoulicensed/certifiedforthejobappliedfor?00;(#.=Yes򀀀No򀀀 = Nameoflicense/certificationAV) (dwE (A , ? IssuingstateAV)hdwEh "A p!PA License/certificationnumberAV) 4dwE P#4A "C Hasyourlicense/certificationeverbeenrevokedorsuspended?00;(#.HYes򀀀No򀀀 <%"G  Ifyes,statereason(s),dateofrevocationorsuspensionanddateofreinstatementAV)tdwE'tA &`#I AV) xdAE/(xA 0(%K AV) xdAE)xA )%M AV) xdAE)xA )&O AV) xdAE*xA *'Q AV) xdAE+xA +(S  -  +(T  EmploymentHistory    XX%& Listbelowallpresentandpastemploymentstartingwithyourmostrecentemployer(last  10yearsissufficient).Accountforallperiodsofunemployment.Youmustcompletethis o sectionevenifattachingaresume. #&%XX0# {[ NameofEmployerAV)@ dwE@ A !  AddressAV),dwE, A e E  TypeofBusinessAV) `dwE E `A    TelephoneNo.(򀀀)򀀀YourSupervisorsName򀀀    YourPositionandDutiesAV) dwE A 1  AV) xdAExA   AV) xdAExA    3DateofEmployment:From򀀀To򀀀   Rateofpay:Starting򀀀Ending򀀀   ReasonforLeaving:AV) dwE A _? AV) xdAExA  AV) xdAExA  AV) xdAExA   T6NameofEmployerAV)@ dwE@ |A $ AddressAV),dwE,A $& TypeofBusinessAV) `dwE `A hH( TelephoneNo.(򀀀)򀀀YourSupervisorsName򀀀 *  YourPositionandDutiesAV) dwE A , AV) xdAE xA  . AV) xdAE!xA !g0  9DateofEmployment:From򀀀To򀀀 !v1 Rateofpay:Starting򀀀Ending򀀀 "3  ReasonforLeaving:AV) dwE $A $ 5 AV) xdAE%xA %"7 AV) xdAE&xA   AV) xdAE'xA '|$;  <   -s*E NameofEmployerAV)@ dwE@ A   AddressAV),dwE,A dD TypeofBusinessAV) `dwE D`A  TelephoneNo.(򀀀)򀀀YourSupervisorsName򀀀   YourPositionandDutiesAV) dwE A 0 AV) xdAE xA    AV) xdAE xA     $@DateofEmployment:From򀀀To򀀀    Rateofpay:Starting򀀀Ending򀀀    ReasonforLeaving:AV) dwE A ^ >  AV) xdAE xA   AV) xdAExA   AV) xdAExA    BNameofEmployerAV)@ dwE@ A  AddressAV),dwE,A K+ TypeofBusinessAV) `dwE +`A o TelephoneNo.(򀀀)򀀀YourSupervisorsName򀀀 !  YourPositionandDutiesAV) dwE A # AV) xdAExA % AV) xdAExA '  PFDateofEmployment:From򀀀To򀀀 ( Rateof_pay:_ԀStarting򀀀Ending򀀀 *  ReasonforLeaving:AV) dwE A E%, AV) xdAExA . AV) xdAExA 0 AV) xdAE xA  2  INote:Attachadditionalpage(s)ifnecessary.  !4  MilitaryService    Haveyouobtainedanyspecialskillsorabilitiesastheresultofserviceinthemilitary?00;(#.eYes򀀀No򀀀   Ifso,describe:AV) dE A  AV) xdAExA w AV) xdAE}xA ~^ AV) xdAEd xA e E  AV) xdAEK xA L ,  AV) xdAE2 xA 3   K References   f   XX%&Listbelowthreepersonsnotrelatedtoyouwhohaveknowledgeofyourworkperformance    withinthelastthreeyears.#&%XXMN#    NameAV)dwE7A { 0O  No.StreetCityStateZip = AddressAV),dwE,A a OccupationAV)$dwE$aA  TelephoneNo.(򀀀)򀀀NumberofYearsAcquainted򀀀    NameAV)dwEqA & Q  No.StreetCityStateZip wW( AddressAV),dwE,WA * OccupationAV)$dwE$A , TelephoneNo.(򀀀)򀀀NumberofYearsAcquainted򀀀 C#. NameAV)dwE"A "4 JT  No.StreetCityStateZip "6 AddressAV),dwE,$A # 8 OccupationAV)$dwE$%A 9%": TelephoneNo.(򀀀)򀀀NumberofYearsAcquainted򀀀 }&]#<   '$> &%%&  #&%&V#&D%&PleaseReadCarefully,InitialEachParagraphandSignBelow#&%&D;W#&%&   AV)dEA0  IherebycertifythatIhavenotknowinglywithheldanyinformationthatmightadversely  affectmychancesforemploymentandthattheanswersgivenbymearetrueandcorrectto  thebestofmyknowledge.IfurthercertifythatI,theundersignedapplicant,have w personallycompletedthisapplication.Iunderstandthatanyomissionormisstatementof oO materialfactonthisapplicationoronanydocumentusedtosecureemploymentshallbe G ' groundsforrejectionofthisapplicationorforimmediatedischargeifIamemployed,    regardlessofthetimeelapsedbeforediscovery .  (#(# AV)dwE%A0  Iherebyauthorizethecompanytothoroughlyinvestigatemyreferences,workrecord,  e  educationandothermattersrelatedtomysuitabilityforemploymentand,further, ]=  authorizethereferencesIhavelistedtodisclosetothecompanyanyandallletters,reports 5  andotherinformationrelatedtomyworkrecords,withoutgivingmepriornoticeofsuch    disclosure.Inaddition,Iherebyreleasethecompany,myformeremployersandallother   persons,corporations,partnershipsandassociationsfromanyandallclaims,demandsor  liabilitiesarisingoutoforinanywayrelatedtosuchinvestigationordisclosure. u(#(# AV)dwEA0  Iherebyagreetosubmittobindingarbitrationalldisputesandclaimsarisingoutofthe  submissionofthisapplication.Ifurtheragree,intheeventthatIamhiredbythecompany,  thatalldisputesthatcannotberesolvedbyinformalinternalresolutionwhichmightarise  outofmyemploymentwiththecompany,whetherduringorafterthatemployment,willbe  submittedtobindingarbitration.Iagreethatsucharbitrationshallbeconductedunderthe }] rulesoftheAmericanArbitrationAssociation.Thisapplicationcontainstheentire U5 agreementbetweenthepartieswithregardtodisputeresolutionand,therearenoother -  agreementsastodisputeresolution,eitheroralorwritten. (#(# AV)dwE-A0  Iunderstandthatnothingcontainedintheapplication,orconveyedduringanyinterview m# whichmaybegrantedorduringmyemployment,ifhired,isintendedtocreatean eE$ employmentcontractbetweenmeandthecompany.Inaddition,Iunderstandandagree =% thatifIamemployed,myemploymentisfornodefiniteordeterminableperiodandmay  & beterminatedatanytime,withorwithoutpriornotice,attheoptionofeithermyselforthe  ' company,andthatnopromisesorrepresentationscontrarytotheforegoingarebindingon !( thecompanyunlessmadeinwritingandsignedbymeandthecompanysdesignated "}) representative.#&%%&圹W#&%%&u#U *(#(#  AV)dwE&A0  IunderstandthatIwillberequiredtopassadrugtest,beforeafinalofferofemployment %". ismade.Bysigningmynamebelow,Iconsenttothisprocedure. #&%%&圎e#&#/(#(#   Date AV)dwE,A0 ` 0 ` (#` (#0 (# (# ApplicantsSignature AV),[ dE,[ A+(7(#(#  %&.TDK:\ADMIN\PERSONNEL\APPLICATION.WPDTK:\ADMIN\PERSONNEL\APPLICATION.WPD/  0  0(#(#0p(#(#0p(#p(#0 (#(#0x (# (#_3/22/12;sw#&% ?h#_