* = Required Information

Yes No
Yes No
In case of emergency notify:
Day Evening Night All
Full-Time Part-Time PRN/per diem Temporary
Sun Mon Tues Wed
Thurs Fri Sat
Yes No
license type 1
license type 2
Yes No

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1 2 3 4
1 2 3 4
Yes No
Yes No
Yes No
Company 1
Company 2
Company 3


The information I have provided in this Application for Employment is true, correct, and complete to the best of my knowledge. False, incomplete, or misrepresented information of any kind will be sufficient cause for my application to be rejected or, if discovered after I am employed, cause for immediate termination.

I authorize FIRST COMMUNITY HEALTH SERVICES, LLC to contact and obtain information about me from previous employers, educational institutes, and "references" I provided, and any other party necessary to verify the accuracy of information contained in this application, all interviews, or resumes. I waive all rights and claims I may otherwise have with FCHS or its representatives, for seeking and using information to evaluate my employment report and all other persons, corporations or organizations who provide information for this purpose.

This application will expire in sixty (60) days. After that date, unless otherwise notified, I understand that my status as an applicant will end. I will then need to re-apply for future employment consideration.

This application is not an employment agreement. If I am offered a position, and accept, I understand FCHS may terminate my employment at any time without cause and without prior notice, unless required by law. I understand that no one, other than administrative personnel, has authority to enter into any employment agreement with term contrary to the forgoing and then only in writing, signed by such personnel. I also fully understand this information is confidential and only the appropriate administrative personnel will have access to your application.

*I fully understand and accept all terms and conditions in the above statement.