Thank you for your interest in NeoHealth. NeoHealth is an equal opportunity employer and complies with State and Federal Employment Laws. If you require assistance in order to complete this application please request assistance from the NeoHealth Human Resources Office. Personal Name: First: Middle: Last: Home Phone: Address: City Cell Phone: State: OK AL AK AR AZ CA CO CT DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MS MO MT NE NC NV ND NH NJ NM NY OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Email Address Position applied for: Site Preference: Any Available Hulbert Health Center Hulbert Pharmacy NeoHealth Medical Center @ NSU NeoHealth Muskogee NeoHealth Pediatrics NeoHealth Women`s Care Center Salina Family Medical Center Tahlequah Extended Care Clinic Tahlequah Family Practice Tahlequah Health Center Tahlequah Pediatrics Westville Family Medical Center Are you eligible to work in the United States? Yes NoHave you ever been employed with NeoHealth? Yes NoDates previously employed with NeoHealth: Education Did you graduate High School or achieve a GED? Yes NoPlease list any University, College, Trade, Business or Correspondence school completed. Name of school Specialty or Major Certification/Degree Earned Training/Skills Are you Bilingual? Yes NoLanguages Spoken: List Training/skills which would qualify you for the position you seek. List all current and valid licenses you hold, such as drivers, RN, LPN, Attorney, Engineer, Accountant, Etc. Type License Number Expiration Date EMPLOYMENT HISTORY List all employment. Begin with your present or most recent job. Job Title: Employer Supervisor Name/Title: Address: City StateOK AL AK AR AZ CA CO CT DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MS MO MT NE NC NV ND NH NJ NM NY OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY , Zip Number of Employees Supervised Employer Phone: Employment Dates: Employment Status: Full Time Part TimeDescription of work performed: Salary: Annually Hourly Are you currently employed with this employer? Yes NoIf so, may we contact your present employer? Yes No Job Title: Employer Supervisor Name/Title: Address: City StateOK AL AK AR AZ CA CO CT DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MS MO MT NE NC NV ND NH NJ NM NY OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY , Zip Number of Employees Supervised Employer Phone: Employment Dates: Employment Status: Full Time Part TimeDescription of work performed: Salary: Annually Hourly Job Title: Employer Supervisor Name/Title: Address: City StateOK AL AK AR AZ CA CO CT DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MS MO MT NE NC NV ND NH NJ NM NY OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY , Zip Number of Employees Supervised Employer Phone: Employment Dates: Employment Status: Full Time Part TimeDescription of work performed: Salary: Annually Hourly AVAILABLITY Please list the times you are available to work: Monday Tuesday Wednesday Thursday Friday Saturday BACKGROUND Have you ever been convicted of any crime other than a minor traffic violation? Yes NoIf yes, list all such offenses: a conviction does not mean you cannot be hired. The offense and how recently you were convicted will be evaluated along with your qualifications in relation to the job for which you are applying. REFERENCES Name Address Job Title and Company Telephone SOURCE- How did you hear about this job vacancy? Social Media: Career/Job Fair, Newspaper Name: , Walk-In, This Website, NeoHealth Employee: , Other: