Application for Employment

Applicant’s Information

Which job are you interested in? *

First *

Last Name *

Address *

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone *

E-Mail *

Date Available *

Desired Salary *

Desired Shift *

Are you a citizen of the United States? *

Yes
No

If no, are you authorized to work in the U.S.? *

Yes
No

Have you ever worked for this company? *

Yes
No

If so, when? *

Have you ever been convicted of a felony? *

Yes
No

If yes, explain *

Please list the names of any friends or relatives who work for this company:

Please list the names of any relatives living at PCCA:

Education

High School Information:

High School *

Address *

From *

To *

Did you graduate? *

Yes
No

Degree

Diploma
GED

College Information:

College

Address

From

To

Did you graduate?

Yes
No

Degree:

Additional College (if applicable)

Address

From

To

Did you graduate?

Yes
No

Degree:

Military Service

Branch

From

To

Previous Employment

First Employer

Company *

Phone *

Address *

Supervisor *

Job Title *

Time *

Full Time
Part Time

Starting Salary

Ending Salary *

Responsibilities *

From *

To *

Reason for Leaving *

Are you eligible for rehire? *

Yes
No

Second Employer

Company

Phone

Address

Supervisor

Job Title

Time

Full Time
Part Time

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

Are you eligible for rehire?

Yes
No

Third Employer

Company

Phone

Address

Supervisor

Job Title

Time

Full Time
Part Time

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

Are you eligible for rehire?

Yes
No

Fourth Employer

Company

Phone

Address

Supervisor

Job Title

Time

Full Time
Part Time

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

Are you eligible for rehire?

Yes
No

How did you learn about Pediatric Complex Care of Arkansas? *

Newspaper:

Disclaimer

The information provided in this application for employment is true, correct and complete. If employed, any misstatement or omission of fact on this application may result in dismissal.

In consideration of my employment, I agree to conform to the rules and regulations of Pediatric Complex Care of Arkansas and further agree that my employment and compensation are at the will of PCCA and can be terminated with or without cause and with or without notice, at any time, at the option of either myself or PCCA. I understand and agree that these terms can be modified by the Administrator. No supervisor, representative, agent, or employee of PCCA has now or has had in the past any authority to enter into any agreement of employment for any specific period of time, or to make any agreement which is contrary to or modification of the above terms, nor can any policies or practices of PCCA either written or oral, modify the above terms.

Should the information obtained from Arkansas Child Abuse and Neglect Registry, State or Federal background check contain documentation of substantiated abuse or neglect of a minor, or any of the 61 offenses listed by the Office of Long Term Care as prohibited by an employee, I understand my employment with Pediatric Complex Care of Arkansas will be immediately terminated.

I hereby authorize all educational institutions which I have attended, all branches of U.S. military service in which I have served, all of my former and current employers, and all of their representatives to furnish to Pediatric Complex Care of Arkansas or its representatives any and all information concerning my education, military services, and/or former/current employment. In addition, I hereby agree to hold harmless and to release all of said educational institutions, military services, employers and representatives from any and all claims that I may have, or which may arise against any and/or all of them, including Pediatric Complex Care of Arkansas, as a result of their furnishing information to Pediatric Complex Care of Arkansas.

Applicant Signature *

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Applicant’s Information

Education

High School Information:

College Information:

Military Service

Previous Employment

First Employer

Second Employer

Third Employer

Fourth Employer

Disclaimer