Employment Application

Your Contact Information

First Name*
Please enter your first name.
Middle Name
Please enter your middle name.
Last Name*
Please enter your last name.
Address*
Please enter your street address.
City/State/Zip*
  
Please enter your city.
Please enter your state.
Please enter your zipcode.
Email Address*
Please enter a valid email address.
Home Phone*
--
Please supply a valid area code.
Please supply a valid phone number prefix.
Please supply a valid phone number suffix.
Mobile Phone
--
Please enter a valid area code.
Please enetr a valid phone prefix
Please enter a valid phone suffix.

Emergency Contact Information

Contact Name*
Please enter the full name of an emergency contact.
Contact Phone*
--
Please enter a valid area code.
Please enter a valid phone prefix.
Please enter a valid phone suffix.

Employment Information

Please select the location that you're interested in applying for:
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Please select the position(s) you would like to apply for:*
Please select at least one position that you're interested in applying for.
Please indicate the shift(s) you're available to work*


Please select at least one shift you're available for.
When are you available to start work?*
Please enter the date you're available to start work.
Please select the schedule(s) you would like to apply for*
Please specify the schedule(s) you're available for work.
Have you filed an application for employment with Health Partners, Inc. before now?*
Please answer Yes or No.
Have you ever been employed by Health Partners, Inc.?*
Please answer Yes or No.
If yes, please supply the date you began employment:
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If yes, please supply the date you ended employment:
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If yes, enter the name you used during employment:
Please enter the full name that you used during your employment. Remove any special characters.
Please indicate the names of any relatives already employed by Health Partners, Inc.
Please remove any special characters.
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?*
Please answer Yes or No.
Proof of citizenship or immigration status may be required upon employment.
If employed and you are under 18, can you furnish a work permit?*
Please answer Yes or No.
Will you submit to a drug screening test?*
Please answer Yes or No.
A drug screening is required for employment at Health Partners, Inc.
Are you capable of performing in a reasonable manner, with or without reasonable accommodation, the activities involved in the job or occupation for which you have applied?*
Please answer Yes or No.
Are you currently employed?*
Please answer Yes or No.
May we contact your present employer?*
Please answer Yes or No.
Are you currently on lay-off and subject to recall?*
Please answer Yes or No.
Are you available for travel if a position requires it?*
Please answer Yes or No.
Specify any travel limitations (distance, routes, types of roads, time of day/night)
Please remove any special characters.

Your History

Have you been convicted of a felony or a misdemeanor involving physical assault, theft, controlled substances, criminal sexual conduct, or embezzlement?*
Please answer Yes or No.
Conviction will not necessarily disqualify an applicant from employment.
If yes, please explain
Please remove any special charaters.
Have you ever been administratively determined by a federal, state or local governmental agency to have committed abuse or neglect in any health care facility?*
Please answer Yes or No.
If yes, when, where and nature of the case:
Please remove any special characters.
Are you on a court-supervised probation or parole?*
Please answer Yes or No.
If yes, please explain:
Please remove any special characters.
Have charges ever been substantiated against you in a Department of Commerce/Department of Consumer and Industry Services or Department of Social Services/Family Independence Agency adult foster care licensing investigation?*
Please answer Yes or No.
If yes, please explain:
Please remove any special characters.
Have charges ever been substantiated against you for abuse, neglect, exploitation, mishandling client funds or any other recipient rights violations in an investigation by:
Department of Commerce/Department of Consumer and Industry Services?*
Please answer Yes or No.
Department of Social Services/Family Independence Agency?*
Please answer Yes or No.
A local Community Mental Health Recipient Rights Office?*
Please answer Yes or No.
Any other recipient rights office?*
Please answer Yes or No.
If yes is answered to any of the above, please explain:
Please remove any special characters.

Your Education

High School Name*
Please enter the name of your High School.
Did You Graduate?*
Please select Yes or No.
High School Location (City/State)*
Please enter the City and State of your high school.
Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities
Please remove any special characters.

 

College/University Name
Please enter the name of the college you attended. Remove any special characters.
How many years of college did you complete?
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Did You Graduate?
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College/University Location (City/State)
Please remove any special characters.
Describe your course of study
Please remove any special characters.
Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities
Please remove any special characters.

 

Graduate / Professional School Name
Please enter the name of the school you attended. Remove any special characters.
How many years of Graduate School did you complete?
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Degree/Diploma
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Graduate School Location (City/State)
Remove any special characters.
Describe your course of study
Remove any special characters.
Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities
Please remove any special characters.
List professional, trade, business or civic activities and offices held:
Please remove any special characters.
You may exclude those which indicate race, color, religion, sex or national origin

Your References

Give the name, address, and telephone number of three references who are not related to you and are not previous employers:

Reference #1

Full Name*
Please enter the full name of your reference.
Address*
Please enter the street address.
City*
  
Please enter the city.
Please select a state.
Please enter the zip code.
Area Code*
--
Please supply a valid area code.
Please supply a valid phone number prefix.
Please supply a valid phone number suffix.

Reference #2

Full Name*
Please enter the full name of your reference.
Address*
Please enter the street address.
City*
  
Please enter the city.
Please select the state.
Please enter the zip code.
Area Code*
--
Please enter a valid area code.
Please enter a valid phone number prefix.
Please enter a valid phone number suffix.

Reference #3

Full Name*
Please enter the full name of your reference.
Address*
Please enter the street address.
City*
  
Please enter the city.
Please enter the state.
Please enter the zip code.
Area Code*
--
Please enter a valid area code.
Please enter a valid phone number prefix.
Please enter a valid phone number suffix.

Employment Experience

Start with your present or last job. Include military service assignments and volunteer activities. Exclude organization names which indicate race, color, religion, sex or national origin.
If there are any periods between these employers when you were not employed, please state the dates you were not employed and the reasons for the non-employment.

Employer #1

Employer Name*
Please enter the employer name.
Address*
Please enter the street address.
City*
  
Please enter the city.
Please enter the state.
Please enter the zip code.
Area Code*
--
Please enter a valid area code.
Please enter a valid phone number prefix.
Please enter a valid phone number suffix.
Job Title*
Please enter your job title.
Supervisor Name*
Please enter your supervisor's name.
Reason for Leaving*
Please enter your reason for leaving this position.
Start Date*
Please enter the date that you started this position.
End Date*
Please enter the date that you left this position.
Was your pay based on:*
Please select an option.
Starting Rate of Pay*
Please enter your starting pay at this company.
Ending Rate of Pay*
Please enter your ending (or current) pay while at this company.
Please describe the work you performed:*
Please describe your work duties while at this position.

Employer #2

Employer Name
Please enter the name of this employer
Address
Please enter the street address.
City
  
Please enter the city.
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Please enter the zip code only.
Area Code
--
Please enter a valid area code.
Please enter a valid phone number prefix.
Please enter a valid phone number suffix.
Job Title
Please remove any special characters.
Supervisor Name
Please remove any special characters.
Reason for Leaving
Please remove any special characters.
Start Date
Please enter the date you start this position.
End Date
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Was your pay based on:
Invalid Input
Starting Rate of Pay
Please remove any special characters.
Ending Rate of Pay
Please remove any special characters.
Please describe the work you performed:
Please remove any special characters.

Employer #3

Employer Name
Please remove any special characters.
Address
Please enter the street address.
City
  
Please enter the city.
Invalid Input
Please enter a zip code.
Area Code
--
Please enter a valid area code.
Please enter a valid phone number prefix.
Please input a valid phone number suffix.
Job Title
Please remove any special characters.
Supervisor Name
Please remove any special characters.
Reason for Leaving
Please remove any special characters.
Start Date
Invalid Input
End Date
Invalid Input
Was your pay based on:
Invalid Input
Starting Rate of Pay
Please remove any special characters.
Ending Rate of Pay
Please remove any special characters.
Please describe the work you performed:
Please remove any special characters.

Employer #4

Employer Name
Please remove any special characters.
Address
Please enter the street address.
City
  
Please enter the city.
Invalid Input
Please enter a zip code.
Area Code
--
Please enter a valid area code.
Please enter a valid phone number prefix.
Please enter a valid phone number suffix.
Job Title
Please remove any special characters.
Supervisor Name
Please remove any special characters.
Reason for Leaving
Please remove any special characters.
Start Date
Invalid Input
End Date
Invalid Input
Was your pay based on:
Invalid Input
Starting Rate of Pay
Please remove any special characters.
Ending Rate of Pay
Please remove any special characters.
Please describe the work you performed:
Please remove any special characters.

Special Skills and Qualifications

Summarize special skills and qualifications acquired from employment or other experience:*
Please tell us about any special skills or qualifications you have that we should consider when reviewing your application.

How did you hear about Health Partners, Inc.?

Referral Source:
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Referral Source Name
Please remove any special characters from your answer.

Acknowledgment and Digital Signature

I certify that answers given in this application are true and complete to the best of my knowledge and understand that false or misleading information or omission of information given in my application or interview(s) may result in rejection of my application or, if hired, dismissal of my employment with Health Partners, Inc.
Please enter your full name.*
Please enter your full name. It will be used to digitally sign this document.
By checking this box, you are digitally signing this application and verifying the accuracy of the information. When you submit the application, your digital signature will be generated automatically.
You must check this box to digitally sign and submit your application to Health Partners, Inc.