Quality Care Rehab Sources

Setting the Standard for Quality Health Care

Quality care is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status. Please read carefully before you sign this application. Application must be completed in full even if attaching a resume.

Date:

Position Applied For:

What made you decide to apply at Quality Care Rehab Sources:

Newspaper

Employment Agency

Current Employee (name)

Contact on my own

Internet

Other

If applicable to position, list your typing speed:

Data Entry Speed:

Name:

Address:

What is your preference? Mark all that apply:

Temporary employment

Full-time employment

Part-time employment

Weekends

Intern

Phone:

Alternate Phone number (cell/beeper):

Email:

Do you have any relatives working for Quality Care Rehab Sources or any of its divisions?

Yes

Have you worked for Quality Care Rehab Sources before?

Yes

Have you ever applied to the Company or any of its divisions before?

Yes

Are you of legal age to work?

Yes

Only U.S. citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, provide genuine documentation establishing your identity and eligibility to be legally employed in the United States?

Yes

Quality Care Rehab Sources is a non-smoking facility. If you smoke can you abstain during your work shift?

Yes

Have you pled nolo contendere, been found guilty, or had adjudication withheld by the court, judge, or jury for a crime that is a felony or first-degree misdemeanor? If yes, please explain:

Yes

Have you ever been discharged from any employment or asked to resign? If yes, please explain:

Yes

Consistent attendance and punctuality are essential requirements of every job with this company. Is there anything which would interfere with your regular attendance and punctuality if you are offered a job with the company? If yes, please explain:

Yes

School	Did you Graduate?	If no G.E.D?
High School	Yes No	Yes No
College	Yes No
Graduate School	Yes No
Other	Yes No

List professional licenses, registration, certification diploma:

Special skills (add information about equipment, languages, software familiarity, data entry skills, etc.):

Submit reasons for periods of unemployment & any supplemental job experience if necessary:

EMPLOYMENT: List last employer first, including U.S. Military Service

Current Employer:

Dates form

Phone Number

Current position

Supervisor Name/Title

Duties

Salary: Start

End

Reason for leaving

May we inquire of your current employer?

Yes

Current/Former Employer:

Dates form

Phone Number

Current position

Supervisor Name/Title

Duties

Salary: Start

End

Reason for leaving

May we contact your current/ former employer?

Yes

Former Employer:

Dates form

Phone Number

Current position

Supervisor Name/Title

Duties

Salary: Start

End

Reason for leaving

May we contact your current/ former employer?

Yes

Reference 1

Reference 2

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The Easiest Way to Get Your Clinic Job

Quality Care Rehab Sources

Setting the Standard for Quality Health Care

EMPLOYMENT: List last employer first, including U.S. Military Service