Optimus Health Care Online Application

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EMPLOYMENT

Human Resourse:
Margarita Torres
P: (203) 696 - 3260 extentions: 3345, or 3386, 3388

Equal Access to programs, services, and employment is available to all persons. Those applications requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Position(s) Applied for:

Date of Application:

Day ,

Referral Source:

Optimus Employee

Relative

Government Employment Agency

Private Employment Agency

Walk-in

Other:

Personal Information

First Name:

Last Name:

Email:

Address 1:

Address 2:

City:

State:

Zip:

Home Telephone:

Best time to call :

Mobile Phone:

Social Security Number:

May we contact you at work?

Yes No If Yes, work number :

Best time to call:

If under 18, can you furnish a work permit ?

Yes No

If No, Please explain:

Have You submitted an application here before?

Yes No if yes, give date(s)

Have you ever been employed here before?

Yes No If yes, dates

Are you legally eligible fo employment in the USA?

Yes No

If No, Please explain:

Date available for work?

Type of employment Desired:

Will you relocate if job requires it?

Yes No

Are you able to meet the attendance requirements of this position?

Yes No

Will you work over time if required?

Yes No

If no please explain:

Have you ever been bonded?

Yes No

Have you ever been convicted of a crime in the last (7) years?

Yes No

If yes, please explain:

Employment History

Provide the following information for your past and current employers, assignments or volunteer activities, starting with the most recent (use additional sheets if necessary). Explain any gaps in employment in comments section below.

Employer:

Telephone:

Address:

Job Title:

Immediate Supervisor and Title

Reason For Leaving:

May we contact for reference:

Yes No

Dates Employed:

From to

Salary:

Job Responsibilities:

Employer:

Telephone:

Address:

Job Title:

Immediate Supervisor and Title

Reason For Leaving:

May we contact for reference:

Yes No

Dates Employed:

From to

Salary:

Job Responsibilities:

Employer:

Telephone:

Address:

Job Title:

Immediate Supervisor and Title:

Reason For Leaving:

May we contact for reference:

Yes No

Dates Employed:

From to

Salary:

Job Responsibilities:

Comments - including explination of any gaps in employment

Skills and Qualifications

Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.

List three (3) schools attented, starting with the most recent

List Number of years Completed:

Indicate Degree earned, if any:

Grade Point Average or Class Rank:

Major Field of study:

Minor Field of study (if applicable) :

References

List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

Name	Telephone	Years Known

Additional Information:

List professional, trade, business, or civic associations and any offices held. Exclude memberships which would reveal sex, race religion, national origin, age, color, disability or any other similarly protected status.

Organization:

Offices Held:

List special accomplishments, publications, awards, etc. Exclude information which would reveal sex, race, religion, national origin, age, color, disabilty or other protected status.

List any additional information you would like us to consider

I understand that if I am employed, any misrepresentation or material omission made my me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employers's service, whenever it is discovered.

I give the employer the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information.

The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employement for any specified period of definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer.

I understand it is this company's policy not to refuse to hire a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA.

I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.

Name : Date: