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Online Employment Application

Full name:

Address:

Home phone:

Business phone:

E-Mail:

18 years of age or over?
Yes No

Social Security Number:

Shift desired:
Day Afternoons Nights 12 Hour

Schedule:
Full time Part time

Position desired or area of interest:

Person to notify in case of emergency
(include address & phone number):

Are you eligible for employment in the United States?
Yes No

Alien Number (if any):

Do you have a current State Professional License/Certification without restrictions?
(only answer if applicable to position for which you are applying)
Yes No

If no, please explain:

What starting salary range do you consider appropriate?

Have you previously applied at this company?
Yes No

If so, date and position:

Have you ever been employed by this company?
Yes No

If so, date and position:

Have you ever been known by or used any other name?
Yes No

If yes, please explain:

Who referred you to this company?
Agency Advertising Employee Other

Do you have any relatives already employed by this company?
Yes No

If yes, please list name and relationship:

List of previous employers - most recent first
note: please give accurate, complete information on all full or part time positions held.

Employer:

Dates of employment:

Supervisors name:

Address:

Telephone number:

Type of business:

Title of position:

Duties (include supervision):

Final salary:

Reason for leaving?

May we contact your present employer?
Yes No

References: List the names of three (3) persons not related to you, whom you have known at least one year and of whom we may make inquiries.

Name:

Address:

Phone number:

Business:

Years known:

Name:

Address:

Phone number:

Business:

Years known:

Name:

Address:

Phone number:

Business:

Years known:

Notice of medical examination: Any offer of employment may be contingent upon your ability to pass a medical examination prior to the commencement of employment.

Military

If you have served, indicate the time period with dates:

Branch:

Highest rank or rating:

Reserve status:

Conviction record:

Have you ever been convicted of a crime?
Yes No

If yes, explain when, where and the nature of the criminal conviction:

Are there any felony charges pending against you?
Yes No

If yes, describe:

Company policy does not render conviction of a crime an absolute bar to employment. Such facts as the seriousness and nature of the offense or violation, how many years ago the offense occurred and rehabilitation will be considered by the company in relation to the specific job which you seek.

Please print, complete, and sign the following forms, then fax or mail to us:
Release Form

Reference Form

Near Redding:
Arcadia Health Care
1716 Court St., Suite B
Redding California 96001
phone: (530) 223-2332
fax: (530) 223-4721

Near Chico:
Arcadia Health Care
2057 Forest Avenue, Suite 7
Chico California 95928
phone: (530) 566-9025
fax: (530) 893-6103

Toll Free: 1-866-976-8773