Application for Employment

Please fill in all spaces if possible
Name - Last First Middle E-mail Social Security No. This Date
Address - Street Telephone No.
City  State  Zip  Best time to reach: 

Have you reviewed a written job description listing the essential job functions of the position(s) for which you have applied?  
If yes, are you able to perform each of the essential job functions listed for each position for which you have applied?  

If no, list the function(s) you are unable to perform and explain why you are unable to perform them.

Have you ever been convicted of a felony or misdemeanor?

If yes, please explain:

Position Desired Training for This Position (Formal education shown on next page)
Current Employer: Reason for Desiring Change
How did you learn of this position?
Professional License Number  Type  State 

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to conduct a criminal background check and to make a thorough investigation of my past employment and activities. I agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to drug testing and to take the placement physical examination which all employees must consent to, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate.

I hereby authorize my current and former employers to release any information, whether contained in my personnel file or otherwise known to them, to NHS that may be requested by them in connection with my application for employment with NHS. I specifically release from liability any current or former employers, their agents, representatives, employees, officers or directors, for giving such information to NHS.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any mis-statement or omission of fact appearing on this application form.