Employment Application Form We consider all applicants for all positions without regard to race, color, religion, sex, age, marital status, veteran status, national origin, the presence of non-job related medical condition or disability or any other protected status. We are an equal opportunity employer. Instructions for Completion Please provide all applicable information as detailed as possible as this will provide us with more background information and increase your chances of employment. Please do not leave any blanks or question unanswered. If a specific questions does not apply, please select 'N/A' (Not Apply). All information provided will be kept confidential unless you otherwise state. Name* First Middle Last Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip/ Postal Code Please attach your resume*Max. file size: 10 MB.Date of Availability* MM slash DD slash YYYY Salary Expectations*Required Responses1. If employed and under 18 years of age, can you furnish a work permit?*1. If employed and under 18 years of age, can you furnish a work permit?* Yes No N/A 2. Have you filed an application with this company before?*2. Have you filed an application with this company before?* Yes No N/A 3. Have you ever been employed with this company before?*3. Have you ever been employed with this company before?* Yes No N/A Please indicate when were you employed with this company.* 4. Are you currently employed?*4. Are you currently employed?* Yes No N/A May we contact your present employer?*May we contact your present employer?* Yes No N/A 5. Are you able to work?*Are you able to work?* Full Time Part Time Temporary 7. Have you ever been excluded from participation in any federally funded health care program, including but not limited to Medicare and Medicaid?*7. Have you ever been excluded from participation in any federally funded health care program, including but not limited to Medicare and Medicaid?* Yes No N/A Please explain:* 8. If licensed, have you ever been sanctioned (disciplined by the licensing board)?*8. If licensed, have you ever been sanctioned (disciplined by the licensing board)?* Yes No N/A Please explain:* 9. Are you currently enrolled as a student at Garden City Community College?*9. Are you currently enrolled as a student at Garden City Community College?* Yes No Consent* I agree to Accelacare Website Privacy Policy.By ticking this box I agree I have read the Privacy Policy above and consent to the given information being used by Accelacare to contact me about this vacancy.Signature*
