Professional Regulation and Criminal Liability Paper

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Pioneer Health Services, Inc.
An Equal Opportunity Employer Referral Source:_________________ We do not discriminate on the basis of race, color, religion, national origin, sex, age, or disability. It is our intention that all qualified applicants are given equal opportunity and that selection decisions be based on job related factors. Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. Use blank paper if you do not have enough room on this application. PLEASE PRINT, except for signature on the back of this application. In reading and answering the following questions are aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job related information. Job Applied For __________________________________________________________________________________ Today’s Date _______________________ Are you seeking Full-Time _____ Part-Time _____ PRN _____ employment? When could you start work? _________________________________________ ___________________________________________________________________________________________________________________________________ (Last Name) (First Name) (MI) (Telephone Number) ___________________________________________________________________________________________________________________________________ (Present Street Address) (City) (State) (Zip Code) Are you 18 years of age or older? Yes _____ No _____ Social Security Number (Optional) ____________________________________________________ Yes _____ No ____

If hired can you submit proof of age Yes _____ No _____ and proof of eligibility to work in the United States _ Have you ever applied here before? Yes _____ No _____

If yes, when? _____________________________________________________________________

Were you ever employed here before? Yes _____ No _____ If yes, when?...
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