* = Required Information
PERSONAL
Name (Last, First, Middle) * Social Security Number
Permanent Address - Number and Street * City State Zip Code
Sex * Email Address * Home Phone Number
Male Female
Do you have the legal right to work in USA? (If Yes, verification will be required) Are you over 18? Cell/Mobile Phone Number
Yes No
Yes No
JOB INTEREST
Position Desired Location or Division Preferred (if any)
Are you seeking Date Available Salary Desired
Full-Time Position PRN
Part-Time Position
Hours Desired Shift Available Days Available
40/Wk
< 40/Wk
Other
Any
Days
Evenings
Nights
Any
Sunday Monday
Tuesday Wednesday
Thursday Friday
Saturday
Preferred Locations of interest to work, Make a list.
Referred by Date of Application
Will you consider split shift work? Will you relocate? Are you willing to travel?
Yes No
Yes No
Yes No
Is this your first time applying for employment with us? Yes No
Have you ever been employed with us? Yes No
If yes, give Facility Name
Dates employed Position
MISCELLANEOUS
Have you ever been convicted of a felony? Yes No
If yes, explain (convictions are not an automatic bar to employment)
Have you ever been excluded from the Medicare or Medicaid program for conduct that would constitute a misdemeanor, gross misdemeanor of a felony under the law?
Yes No
If yes, explain (convictions are not an automatic bar to employment)
Have you ever been disciplined by professional of state ethic or licensing board?
Yes No
If yes, explain (convictions are not an automatic bar to employment)
Do you have a working knowledge of the fundamental job duties (essential function) of the position for which you are applying? Yes No
If yes, can you perform the essential functions of the job with reasonable accommodation? Yes No
Are you related to anyone employed by Gem Rehab? (To be used for assignment purposes)
Yes No
Name(s)
Position
Location
The policy of this Company is to provide every individual a fair and equal opportunity to seek employment and advancement at the Company without regard to race, color, religion, sex age, national origin, citizenship status, veteran status, disability or factors protected by state or local laws. An Equal Opportunity Employer.
ALL APPLICANTS
Please read carefully before signing

I certify that any information I give during the course of applying for employment is true and complete. I understand that any false, incorrect or misleading information or the omission of any pertinent information including that given at the time my application may be considered as sufficient reason for my discharge, if hired. I further understand that this application is not intended to be a contract of employment and that, if I am hired, my employment is at will and can be terminated by either me or the Company, with or without notice, for any or no reason. No supervisor or manager has authority to make an agreement to the contrary changing employment at will. This application will be in effect for 90 days from the date indicated below and, if employment is not offered within the 90-day period, I understand that I must reapply to be considered for future employment. I also understand that this application for employment in no way obligates the Company to employ me.

I hereby authorize Gem Rehab to investigate my former employment and other references and to make any further investigations deemed necessary in connection with my application for employment and I do hereby release Gem Rehab and all informants of all liability whatsoever resulting from such investigations.
DATE
Supplement to employment application

I understand that an offer of employment I may receive is subject to my subsequent completion, satisfactory to the Company, of all pre-employment procedures, including submission of documents establishing my rights to work in the USA.
DATE
EDUCATION
High School
School name and address Type of degree earned
Major Type of degree earned
Graduated Grade Point Avg.
Yes No
Business Trade, Technical or Vocational
School name and address Type of degree earned
Major Type of degree earned
Graduated Grade Point Avg.
Yes No
College or University
School name and address Type of degree earned
Major Type of degree earned
Graduated Grade Point Avg.
Yes No
College or University
School name and address Type of degree earned
Major Type of degree earned
Graduated Grade Point Avg.
Yes No
Further Education Planned
EDUCATION
List office equipment you can operate
Typing (WPM) Shorthand (WPM)
Computer hardware Computer software
What official language do you speak? (Respond if you believe this information is relevant to the position applied for)
Do you have any commitment to another employer or business which might affect your employment with us? Yes No
If Yes, Explain
PROFESSIONAL LICENSURE / CERTIFICATION
TYPE NUMBER EXPIRATION CURRENT STATE
WORK HISTORY
List names and address of all former employers, beginning with the most recent. (Attach additional sheet if necessary)
Employer 1
Employers name and address Nature of business
Dates of Employment From/To Position/Title
Rate of pay: Starting/Last Reason for Leaving
Supervisor's name, Title and Telephone
Employer 2
Employers name and address Nature of business
Dates of Employment From/To Position/Title
Rate of pay: Starting/Last Reason for Leaving
Supervisor's name, Title and Telephone
Employer 3
Employers name and address Nature of business
Dates of Employment From/To Position/Title
Rate of pay: Starting/Last Reason for Leaving
Supervisor's name, Title and Telephone
Employer 4
Employers name and address Nature of business
Dates of Employment From/To Position/Title
Rate of pay: Starting/Last Reason for Leaving
Supervisor's name, Title and Telephone
Please indicate by number which employer you do not wish us to contact (prior to employment)
List any additional skills, knowledge, experience or other relevant qualifications that might benefit the Company
REFERENCES
Business and Personal (Do not include relatives)
Reference 1
Name Position or Occupation
Relationship Address
Years Known Telephone
Reference 2
Name Position or Occupation
Relationship Address
Years Known Telephone
Reference 3
Name Position or Occupation
Relationship Address
Years Known Telephone
Reference 4
Name Position or Occupation
Relationship Address
Years Known Telephone
DRIVER'S LICENSE
Driver License No. Date of Expiration
State Issued Type of License
Operator Commercial Chauffeur
Other
Class of License
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes No
Has any license, permit or privilege ever been suspended, denied or revoked?
Yes No
If the answer to either of these questions is yes, attach a statement giving details.
Attach Resume