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EMPLOYMENT APPLICATION
Nepit Solutions
/
EMPLOYMENT APPLICATION
Step
1
of
4
- APPLICANT
25%
Applicant’s Name
First
Middle
Last
Date of Application
Month
Day
Year
Applicant’s Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Applicant’s Email Address
Home Telephone
Cell Phone
Best time to reach you
Position(s) you wish to apply for (list job titles)
Status Desired
Full Time
Part Time
Temporary
Per Diem
Are you willing to travel to various HAN sites?
Yes
No
Limited
Are you willing to work overtime?
Yes
No
Limited
Date Available for Work
Month
Day
Year
Have you filed an application or been employed here before?
Yes
No
If yes give date(s)
Month
Day
Year
Are you 18 years of age or older?
Yes
No
Are you eligible to be lawfully employed in the United States?
Yes
No
proof of citizenship or immigration status will be required upon employment.
List any friends or relatives employed by Health Access Network. What is the relationship?
Have you ever been convicted of a crime?
Yes
No
If yes, provide all detail*
*Conviction of a crime will not automatically disqualify you from employment.
Are you licensed to drive?
Yes
No
If Yes, in what state?
Licence #
Is your license currently under suspension for any reason?
Yes
No
If under suspension, please explain
EMPLOYMENT EXPERIENCE
(List each job held. Start with your present or last job. Include military service assignments and volunteer activities.)
Date From
Month
Day
Year
Date To
Month
Day
Year
Employer Name
Employer Address
Employer's Phone Number
Job Title
Starting Salary/Hourly Rate
Final Salary/Hourly Rate
Supervisor
Reason for Leaving
Work Performed
May we contact?
Yes
No
Are you known by another name?
Yes
No
If yes, What name?
EMPLOYMENT GAPS
PLEASE EXPLAIN GAPS IN EMPLOYMENT GREATER THAN 90 DAYS
Dates
Reason
REFERENCES
(List professional references only. Do not list friends or relatives.)
Name
Title & Place of Employement
Phone Number
Are you known to schools by another name?
Yes
No
If Yes, what name(s) are you known by?
PRE-EMPLOYMENT STATEMENT
Consent
*
I represent that my responses set forth in this application are truthful, accurate, and complete. Any and all false or inaccurate statements made by me in this Application or otherwise during the employment evaluation process shall be grounds both for rejecting my Application for employment and, should I be hired by Health Access Network (HAN), termination of my employment.
I authorize representatives of HAN to contact educational institutions, state and federal agencies (to conduct criminal history records checks) and employers designated in this Application for purposes of verification and investigation of my educational, criminal record, and employment background and performance. Such individuals and organizations are authorized to release such information as may be requested by a HAN representative. I hereby release all such persons from liability or damages incurred as a result of furnishing such information. I understand that an unsatisfactory reference shall be grounds both for rejecting my Application for employment and, should I be hired by HAN, termination of my employment. Should I be employed by HAN, I understand that I could be subject to an outside probe if accused of wrongdoing.
Please be aware that HAN is required to report new hire information to the State of Maine, Department of Human Services, Division of Support Enforcement and Recovery weekly or within 7 days of the date of hire. HAN complies with this legal requirement.
I certify that I am neither suspended nor excluded from participation in Medicare health programs under provisions of sections 1128 or 1156 of the Social Security Act.
Submission of the application does not entitle me to be interviewed by HAN. Further, nothing in this Application or in the employment evaluation process shall be construed as either an offer of employment or an obligation on the part of HAN to provide any benefit to me.
After reading all of the terms of this application. I herby affirm that I understand and agree to the provisions of the same. I also agree that my employment with HAN is on an “at-will” basis, meaning that such employment may be permanently discontinued by either HAN (through discharge or lay/off) or myself through voluntarily quitting at any time without notice. I agree to conform to HAN’s policies and I also agree that I shall be subject to other conditions, which HAN may adopt.
I hereby affirm that I understand and agree the above terms :
Applicants Full Name
*
First
Last
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