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Employment Application

Prolific Health Programs

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Employment Application

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Non-Discrimination Policy: Prolific Health Programs is committed to the principle of equal opportunity in education and employment. Prolific Health Programs does not discriminate on the basis of sex, race, color, creed, national origin, age, religion, sexual orientation, gender identity, gender expression, veteran status, or disability in admission to, access to, treatment in, or employment in its programs and activities.
GENERAL INFORMATION
Date
MM slash DD slash YYYY
Position(s) Applied For
Name*
First Last
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Email
Cell Phone
Are you currently employed?
- Yes
- No
May we contact your employer?
- Yes
- No
Employment desired
- Full-Time
- Part-Time
- Shift Work
- Temporary
- Overtime
When are you available for work?
MM slash DD slash YYYY
Can you travel if a job requires it?
- Yes
- No

EDUCATION
High School
Name & Location
Number
Please enter a number from 1 to 10.
Major / Degree
College
Name & Location
Number
Please enter a number from 1 to 10.
Major / Degree
Graduate School
Name & Location
Number
Please enter a number from 1 to 10.
Major / Degree
Bus. or Trade School
Name & Location
Number
Please enter a number from 1 to 10.
Major / Degree
Professional School
Name & Location
Number
Please enter a number from 1 to 10.
Major / Degree
Special Honors

COMPUTER SKILLS
Check off those computer skills with which you are proficient (any version).
- PC Use
- Windows
- Macintosh User
- Microsoft Excel
- Microsoft Word
- Microsoft Access
- Microsoft Publisher
- Web Page Design/ Maintenance
- E-mail
- Internet
- Other
Other Skills (Please List)

PROFESSIONAL LICENSE

(Only for positions which require professional license or certification)
Do you have a current license?
- Yes
- No
Professional license number
State of Issue
Expiration date
MM slash DD slash YYYY

MILITARY
Are you a veteran of the United States military service?
- Yes
- No
What branch?
Date Entered
MM slash DD slash YYYY
Date Discharged
MM slash DD slash YYYY
Please describe any special skills or training acquired while in the service:

OTHER SPECIAL SKILLS

Please list other special skills you may have, e.g., fluency in other languages, licenses, special training required for the position for which you are applying, etc.

WORK EXPERIENCE

Please list your work experience beginning with your most recent job. If you were self-employed, give firm name. Attach additional sheets if necessary. Exclude organization names which indicate race, color, creed, national origin, age, religion, sexual orientation, gender identity, gender expression, veteran status, or disability.
Most Recent Employer
Date Employed From
MM slash DD slash YYYY
Date Employed To
MM slash DD slash YYYY
Address
Supervisor
Job Title
Reason for Leaving
Work Performed
Need to add more work experience?*
- Yes
- No
Employer
Date Employed From
MM slash DD slash YYYY
Date Employed To
MM slash DD slash YYYY
Address
Supervisor
Job Title
Reason for Leaving
Work Performed
Add more work experience?*
- Yes
- No
Employer
Date Employed From
MM slash DD slash YYYY
Date Employed To
MM slash DD slash YYYY
Address
Supervisor
Job Title
Reason for Leaving
Work Performed
Any more work experience?*
- Yes
- No
Employer
Date Employed From
MM slash DD slash YYYY
Date Employed To
MM slash DD slash YYYY
Address
Supervisor
Job Title
Reason for Leaving
Work Performed

REFERENCES

Please list two references other than relatives or previous employers.
Name
Name
Position
Position
Company
Company
Address
Address
Phone
Phone

WAIVERS AND DISCLOSURES

Please read each section carefully and sign where indicated

AT-WILL EMPLOYMENT

It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this organization. I understand and agree that, if hired; my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or my employer. I also understand that this written statement supersedes any and all oral representations made by agents or representatives of this organization.

CERTIFICATION OF TRUTH AND ACCURACY

I certify that the information in this application is true, complete and correct. I understand that false answers, statements, or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge.
Signature

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*Prolific Health Programs Accepts
Active Medical Assistance & Medicare.

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Here at PHP we are a family oriented, recovery driven organization. We are firm believers that it takes a village to foster and cultivate a caring environment to make a difference. Your support will mean the world to us. Whether you choose to donate your time, talent, or treasure, your contribution directly impacts the lives of our participants, their families, and our staff . Your generosity will make a huge impact to our family.

We will appreciate monetary donations, gift cards, Educational & Recreational tickets to local museums & concerts, Bus passes, Used or new clothing & shoes, Non- perishable food items, house hold supplies, shopping, restaurants ,Just to name a few. Again, any small or large donation will make a significant difference to our participants. We thankyou so much !

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Programs Hours:
Monday-Friday: 9:00-5:00 PM
Saturday: By Appt Only
Sunday: Closed

Telephone:
Office: (410)878-7511
Fax: (410)878-7119
Email: info@prolifichealthprograms.com

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