PHC of Pinellas

Application for Employment
(Please print clearly)

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Name:

Address:

Primary Telephone:

E-mail Address:

Position(s) applying for:

Date of Application

Referral Source
(Please check the appropriate category and list the source.)

Category

Source

 Walk-in
 Employee
 Company's Website
 Other Internet
 School
 Other

If you are under 18 and it is required, can you furnish a work permit?

 Yes No
If no, please explain:

Have you submitted an application here before?

 Yes No
If yes, give date(s) and position(s):

Have you ever been employed here before?

 Yes No
If yes, give dates and position:

Are you legally eligible for employment in the United States?

 Yes No

Date available for work:

What is your desired salary range or hourly rate of pay?

Type of employment desired:

 Full-Time Part-Time Temporary

Will you work overtime if required?

 Yes No

Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodations)?

 Yes No Need more information about the job's essential functions to respond

Have you ever committed, been convicted of, pled guilty to, pled nolo contendere ("no contest") to a felony or misdemeanor?

 Yes No
If yes, please provide date(s) and details:

Note: A "yes" answer to these questions will not automatically disqualify a candidate from employment. The nature, job relatedness, severity and date of the offense in relation to the position for which applying are considered.

Employment History
(Start with your most recent employer, please provide the following information)

Employer

Telephone #

Dates employed:

Starting Job Title

Final Job Title

Compensation (Starting)

 Hourly Salary

Compensation (Final)

 Hourly Salary

Immediate supervisor (for most recent position held)

May we contact for reference?

 Yes No Later

Why did you leave?

Summarize the type of work performed and job responsibilities


Employer

Telephone #

Dates employed:

Starting Job Title

Final Job Title

Compensation (Starting)

 Hourly Salary

Compensation (Final)

 Hourly Salary

Immediate supervisor (for most recent position held)

May we contact for reference?

 Yes No Later

Why did you leave?

Summarize the type of work performed and job responsibilities


Employer

Telephone #

Dates employed:

Starting Job Title

Final Job Title

Compensation (Starting)

 Hourly Salary

Compensation (Final)

 Hourly Salary

Immediate supervisor (for most recent position held)

May we contact for reference?

 Yes No Later

Why did you leave?

Summarize the type of work performed and job responsibilities


Employer

Telephone #

Dates employed:

Starting Job Title

Final Job Title

Compensation (Starting)

 Hourly Salary

Compensation (Final)

 Hourly Salary

Immediate supervisor (for most recent position held)

May we contact for reference?

 Yes No Later

Why did you leave?

Summarize the type of work performed and job responsibilities


Explain any gaps in your employment:

Have you ever been fired or asked to resign from a job?

 Yes No

If yes, please explain:

Certifications:
List licenses and/or certifications, skills, special training that may assist you in performing the position for which you are applying:

Educational Background
Starting with your most recent school attended, provided the following information.

School

 Diploma GED Degree Certification Other

School

 Diploma GED Degree Certification Other

School

 Diploma GED Degree Certification Other

References
List names and telephone numbers of (3) work/business references who are not related to you.
If not applicable, list (3) school or personal references who are not related to you.

Reference

Reference

Reference

Social Security Number:
We will use this information only for employment purposes and make reasonable efforts to safeguard your privacy.

Application Statement

I certify that all the information I have provided in order to apply for and secure work with this employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employee or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and education institutions and to otherwise verify the accuracy of all information provided by me in the application, resume or job interview.

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

If I am hired; I understand that PHC is an "At Will" employer and I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or 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 CEO or Human Resources Director.

I understand PHC is drug free. All offers of employment are contingent on drug screen and background check results. I understand if hired, continued employment is based on compliance with PHC's background and alcohol/ drug programs which are in accordance with federal, state and local law.

I understand that if I am hired, my employment will be subject to a probationary period, which ordinarily will not exceed 90 days from the date I am hired. If I am discharged at any time during the probationary period for unsatisfactory performance, I understand that this employer will not be charged for any unemployment benefits that may be paid to me for work I performed during the probationary period.

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

This Company does not tolerate unlawful discrimination in its employment practices. No questions on this application is used for the purpose of limiting or excluding an applicant from consideration of employment on the basis of his or her sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. The Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic material, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as vendor or customer). The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

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 (i) eliminate me from further consideration of employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Signature of Applicant

Date

Attach your resume (.pdf only)