ELECTRONIC APPLICATION
FOR EMPLOYMENT
Manatee County Rural Health Services, Inc.
Human Resources/Personnel Department
U.S.Hwy. 301 & 71st Street East
P.O.Box 499
Parrish, Florida 34219
(Please Print and Answer All Questions Completely)

Manatee County Rural Health Services, Inc is an Equal Opportunity Employer which makes employment decisions without regard to race, color, sex, religion, national origin, age, handicap, disability, or marital status. The Company also reasonably accommodates individuals with handicaps, disabilities, and bona fide religious beliefs. All applicants must be forwarded to the above mentioned address.

Manatee County Rural Health Services, Inc. is a DRUG-FREE Workplace.

All fields marked with * must be completed.
*1. Select position applying for:

  

2. How Did You Learn About Us?

Advertisement    Friend    Walk-In    Employment Agency    Internet   

Other  

*3. NAME

Last     First     Middle   
*4.1 Address

Street     City     State   

  Zip   

4.2 E-mail:
5. Telephone Number ( )   -

    Cell Phone Number ( )   -

6. Are you 18 years of age or older? If not state your age.

7. Are you presently employed?

*8. Date you are available to start work.

*9. Check all that apply. Full-Time    Part-Time    Temporary On-Call

*10. Have you ever applied or worked here before? Yes    No

If yes, provide dates:   

*11. Is there any reason that you cannot work nights or weekends?    Yes   No

*12. Will you work overtime, if required?    Yes   No

*13. Can you within three days, submit documentation verifying that you are eligible to
work in the United States?

             Yes   No

*14. Have you ever been convicted of a felony crime or misdemeanor? Yes    No

If yes, please explain:

  

15. List any relatives or friends currently employed here:

            

16. Indicate any and all foreign languages you can speak, read, and/or write:

            

17. List any related skills, training, or cultural experiences you believe
are relevant to the job applied for:

  

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*18. In Case of Emergency, Please Contact:
Name: Relationship:
Address: Telephone:


Name: Relationship:
Address: Telephone:

*19. Have you ever been discharged or forced to resign from previous employment?        Yes         No
If yes, please explain:

  

*20. Have any disciplinary actions been taken against you in the last 12 month of active employment involving assault or battery?    Yes         No
If yes, please explain:

  

21. Were you given a performance evaluation within the last 12 month of active employment?        Yes         No
If yes, can you submit a copy of the evaluation?    Yes    No

*22. Have you signed any non-complete agreement with any other employer or agency that would restrict you from working with this Company?        Yes         No
If so, please explain:

  
*23. Have you ever been a defendant in a civil action in an intentional tort such as any form of assault or battery?



24. EMPLOYMENT HISTORY    (Please complete, beginning with most recent employer)
* EMPLOYER 1
(Current or most recent)
Company Name Tel. #
Address:
Date Employed:          From:         To:   
Supervisor's Name:  
Weekly Salary:             Start:         End:   
Reason for Leaving:    

State Job Title and Describe Job Duties (max length 150 characters):

  
EMPLOYER 2
Company Name Tel. #
Address:
Date Employed:          From:         To:   
Supervisor's Name:  
Weekly Salary:             Start:         End:   
Reason for Leaving:     

State Job Title and Describe Job Duties (max length 150 characters):

  
EMPLOYER 3
Company Name Tel. #
Address:
Date Employed:          From:         To:   
Supervisor's Name:  
Weekly Salary:             Start:         End:   
Reason for Leaving:     

State Job Title and Describe Job Duties (max length 150 characters):

  
EMPLOYER 4
Company Name Tel. #
Address:
Date Employed:          From:         To:   
Supervisor's Name:  
Weekly Salary:             Start:         End:   
Reason for Leaving:     

State Job Title and Describe Job Duties (max length 150 characters):

  
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25. EXPERIENCE (total number of years in current profession);    

*26. Please explain any gaps in employment history or any time off relating to Workman's Compensation:

  
*27. DRIVING RECORD

Do you have a Valid Driver's License?         Yes         No
License No.    State   

Have you had any tickets in the last 7 years?         Yes         No
If yes, please explain:   

Has your license ever been suspended or revoked?         Yes         No
If yes, please explain:   

Do you have any DUI or DWI convictions?         Yes         No
If yes, please explain:   
28. FOR LICENSED OR REGISTERED APPLICANTS ONLY

Are You Licensed in FL?         Yes         No    if no what state   

Title:            Licensed         Registered         Certified (COPY REQUIRED)
Specialty:         Certificate No.        
Renewal No.         Expiration Date:        
*29. EDUCATIONAL HISTORY
N/A   School Name & Location From (Mo/Yr) To (Mo/Yr) Degree or
Certification
     High School



     Trade, Tech, or Business School


     College


     Correspondence, Extension School




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Resume



** If you have a resume, please copy and paste in this section **


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APPLICANT'S ACKNOWLEDGMENT

Please Read before electronically signing.


I understand that any employment offer is contingent upon the results of a drug testing being negative. All hiring and employment at Manatee County Rural Health/services, Inc. (MCRHS, INC.) is at will. I understand this application is not an employment contract, nor can it be used to create one. Employment by MCRHS has no specific term and may be terminated by the employee or MSCRH with or without notice. I acknowledge that MCRHS has not made any promises or representations that differ from those contained in this paragraph.
I understand I must provide satisfactory documents to establish my identity and right to work in the United States, if I am offered a position with MCRHS, and that failure to provide this evidence will result in the termination of my employment.
I release and agree to hold harmless any individual, company, business institution or government agency from all liability with regard to furnishing information to MCRHS. I agree to release and hold harmless MCRHS from all liability with respect to the receipt of such information.
I acknowledge that this application will remain active for six months from this date. If I have not heard from the Company at the conclusion of this six-month period, it is my responsibility to complete and submit a new application if I still wish to be considered for employment by the company.
APPLICANT STATEMENT AND RELEASE
I certify that the information provided in my application for employment with Manatee County Rural Health Services, Inc. is true and complete to the best of my knowledge. I authorize the investigation of all matters contained in this application and hereby give Manatee County Rural Health Services, Inc. permission to contact schools, previous employers, references, and others. I hereby release Manatee County Rural Health Services, Inc. form any liability as the result of such contact. I understand that misrepresentations, omissions of fact or incomplete information provided on my application or resume may remove me from further consideration for employment. In addition, if I am employed, I understand that any misrepresentation or omissions of fact on my application or resume may subject me to discipline, up to and including discharge, at any time without any previous notice.
Your typed name will act as your signature:

  * 		Date:                     
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RELEASE TO GIVE REFERENCE
In order to provide Manatee County Rural Health Services, Inc. with information and opinions that may be useful in its hiring decisions, I hereby authorize any person, school, current or past employer, organization or entity disclosed in my resume, application, or during my interview to provide any information regarding me, including without limitation, information concerning my performance, reputation and character. I acknowledge that the information divulged may be negative or positive with respect to me. Nevertheless, pursuant to this authorization, I unconditionally release such person, school, employer, organization or entity from any and all legal liability for furnishing such information and in making such statements.

A photo copy or facsimile copy of this signed release shall have the same force and effect as the original release signed electronically by me.
Your typed name will act as your signature:

   * 		Date:                   


MANATEE COUNTY RURAL HEALTH SERVICES, INC. IS A DRUGFREE WORKPLACE
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