PersonalPosition Applied ForWho were you referred by?How did you hear about this position?Name(Required) First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone(Required)Email(Required) Are you either a U.S. Citizen or permitted under your present visa or immigration status to work in this country?(Required)NOTE: Proof of identity and ability to lawfully work in this country is required prior to or immediately upon employment. Yes NoAre you at least 18 years of age?(Required) Yes NoAre you able to perform essential functions of the job for which you are applying with or without a reasonable accommodations?(Required)Please review job description before answering this question. Yes NoDate you are available for work? MM slash DD slash YYYY Will you accept another position? Yes NoIf yes, please specifyStarting Salary NeededCan you work overtime? Yes NoCan you work weekends? Yes NoApplying for Full-Time Part-Time Temporary PRNWere you previously employed at an SMP Health Facility? Yes NoIf yes, please specify where, when, and in what capacity?Have you ever been convicted of a crime involving mistreatment, neglect, abuse, assault, homicide, sex offenses, domestic violence, theft, fraud, misappropriation of another person's property, conspiracy, weapons, drugs, adulteration of food, or any other crime against person or property?(Required) Yes NoIf Yes, give date(s), offense(s), and dispositionHave you ever been excluded from participation in any federal or state medicare, medicaid or any other third party payor program or have such pending action?(Required)If Yes, a letter showing reinstatement is required for further consideration for employment. Yes NoEducationHigh SchoolAddressCourse of StudyDid you graduate? Yes NoCollegeAddressCourse of StudyDid you graduate? Yes NoTechnical SchoolAddressCourse of StudyDid you graduate? Yes NoOther (specify)AddressCourse of StudyDid you graduate? Yes NoWork ExperienceExperience Employer Job title Supervisor Address Phone Date Employed: From Date Employed: To Ending Wage Duties / Responsibilities Reason for Leaving May we contact this employer?Actions EditDelete There are no Entries. Add Entry Maximum number of entries reached. Employment ReferencesNameAddressPhoneRelationshipNameAddressPhoneRelationshipNameAddressPhoneRelationshipDo you have a friend or relative working here? Yes NoIf Yes, Name, Relationship, and DepartmentProfessional Licenses, Registration, and/or CertificationsDo NOT Include Driver's LicenseTypeState IssuedDate Issued MM slash DD slash YYYY Expires MM slash DD slash YYYY NumberEligibleTypeState IssuedDate Issued MM slash DD slash YYYY Expires MM slash DD slash YYYY NumberEligibleAttach Cover LetterAccepted file types: pdf, doc, docx, txt, Max. file size: 8 MB.Attach Resume(Required)Accepted file types: pdf, doc, docx, txt, Max. file size: 8 MB.Important Notice to All ApplicantsIf you are selected for employment you must be prepared to verify your eligibility to work as required under the Immigration Reform and Control Act of 1986. This requirement applies to all new employees including U.S. citizens, permanent residents and non-immigrants. You will have to provide documents within 3 days of your hire date to verify your identity and eligibility to work.An Equal Opportunity EmployerAll qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, veteran status, or any other characteristic protected by law. Please direct any request for reasonable accommodations needed during the application process to administrator.Applicant's StatementPlease read and sign:I have read and agree to the above statements(Required) AgreeSignature(Required)CommentsThis field is for validation purposes and should be left unchanged.