Employment Application

Careers

NWF Health Network Employment Application

Upon submitting the application below, you will receive a confirmation email with a PDF of your application. If you want to apply for a different position in the future, you can update that PDF as needed and email it to [email protected].

Please only click submit once when you finish the application.

NWF Health Network Employment Application (Revised)

Step 1 of 5

20%

Your Personal Information

Please complete this application in its entirety. Incomplete applications may be excluded from consideration. Resumes are not accepted in lieu of completed application form.

Date(Required)

Month

Day

Year

Your Email Address(Required)

Your Name(Required)

First Last

Present Address(Required)

Street Address Address Line 2 City State ZIP Code

Previous Address(Required)

Street Address Address Line 2 City State ZIP Code

Telephone Number(Required)

Referred By:

Driver's License No. and State:

Does anyone related to you work for NWF Health Network, Camelot Community Care, Children’s Home Society of Florida, Disc Village, Inc., Families First Network, Twin Oaks?(Required)

If yes, state the relative’s name and agency they work for:

May we contact your present employer?(Required)

Yes

May we contact your previous employer?(Required)

Yes

Please identify any exceptions and give reasons for not contacting your present or previous employer.

Position(s) for which you are applying:(Required)

Date you can start:(Required)

Rate of pay desired: $

per:

EDUCATION

High School or GED

School & Location

Years Completed

High School or GED

Graduation

Yes

College

School & Location

Years Completed

Degree & Major

College

Graduation

Yes

Graduate School

School & Location

Years Completed

Degree & Major

Graduate School

Graduation

Yes

Business or Other Training

School & Location

Years Completed

Degree & Major

Field Work Placements

Dates and agencies

CRIMINAL HISTORY

Are you 18 years or old?

Yes

How long have you lived in this area?

Have you ever been convicted of a crime?

Yes

Have you ever pled guilty or no contest to a crime?

Yes

If yes, please give details:

Date, place, offense(s), disposition, etc.

Have you ever been charged with a crime and either been placed on a court ordered probation, had adjudication withheld, or entered a pretrial intervention program?

Yes

If yes, please give details:

Date, place, offense(s), disposition, etc.

WORK EXPERIENCE

List below previous employers and salary history during the last ten years beginning with your current or most recent employer. (Upload additional pages if necessary)

Your Previous Employers

Please list your previous employers, the dates you worked and the position you held

Employer

From (mo/yr)

To (mo/yr)

Employer Address

Street Address City State / Province / Region ZIP / Postal Code

Position

Reason for Leaving

Supervisor Name and Phone Number

Duties

Do you have additional previous employers to include?(Required)

Yes

Your Previous Employers

Please list your previous employers, the dates you worked and the position you held

Employer

From (mo/yr)

To (mo/yr)

Employer Address

Street Address City State / Province / Region ZIP / Postal Code

Position

Reason for Leaving

Supervisor Name and Phone Number

Duties

Do you have additional employers to include?(Required)

Yes

Your Previous Employers

Please list your previous employers, the dates you worked and the position you held

Employer

From (mo/yr)

To (mo/yr)

Employer Address

Street Address City State / Province / Region ZIP / Postal Code

Position

Reason for Leaving

Supervisor Name and Phone Number

Duties

Do you have additional previous employers to include?(Required)

Yes

Your Previous Employers

Please list your previous employers, the dates you worked and the position you held

Employer

From (mo/yr)

To (mo/yr)

Employer Address

Street Address City State / Province / Region ZIP / Postal Code

Position

Reason for Leaving

Supervisor Name and Phone Number

Duties

Do you have additional previous employers to include?(Required)

Yes

Your Previous Employers

Please list your previous employers, the dates you worked and the position you held

Employer

From (mo/yr)

To (mo/yr)

Employer Address

Street Address City State / Province / Region ZIP / Postal Code

Position

Reason for Leaving

Supervisor Name and Phone Number

Duties

Do you have additional previous employers to include?(Required)

Yes

Your Previous Employers

Please list your previous employers, the dates you worked and the position you held

Employer

From (mo/yr)

To (mo/yr)

Employer Address

Street Address City State / Province / Region ZIP / Postal Code

Position

Reason for Leaving

Supervisor Name and Phone Number

Duties

Do you have additional previous employers to include?(Required)

Yes

Additional Previous Employers

If you have additional previous employers to include, please upload a document that includes the following information: the employer, month and year you started and left the job, the employer's address, position held, reason for leaving, supervisor's name and phone number, and your duties in that position.

Max. file size: 50 MB.

Did you work for any of these employers under a different name?(Required)

Yes

If yes, which employer(s) and under what name(s):

Please explain any gaps in your employment history:

Have you received any written reprimands or disciplinary suspensions during any previous employment?(Required)

Yes

If yes, please explain:

Include by whom, when, and for what

Have you ever been discharged or asked to resign?(Required)

Yes

If yes, please explain:

Include by whom, when, and for what

DRIVING HISTORY

(If probability of driving a company vehicle or on company business exists for the position in which you are applying)

Are you able to travel if a job requires it?(Required)

Yes

Do you have a valid driver's license?(Required)

Yes

What class of license do you possess?(Required)

Have you had a suspension or probation of your license within the last five (5) years?(Required)

Yes

How many speeding or other moving violations have you received in the last three (3) years?(Required)

List below all other traffic violations (except parking) on your record for the last three (3) years and all accidents for which you are responsible:

Include date, description, and results

EMPLOYMENT APPLICATION CERTIFICATION(Required)

I hereby certify that all of the facts and information listed on this employment application are true and complete. I understand that any false, incomplete or misleading information given by me on this application is sufficient cause for rejection of this application. I also understand and agree that any such false, incomplete, or misleading information discovered on this application or provided in the hiring process including but not limited to any preliminary screening applications, applications completed or information submitted or provided to Big Bend Community Based Care, Inc. d/b/a NWF Health Network (NWFHN) which is discovered at any time after I am employed may result in my dismissal.

I hereby authorize NWFHN to investigate all statements contained in this application and to interview the references and previous employers listed in this application. I authorize the references and previous employers listed to give NWFHN all facts, opinions and evaluations concerning my previous employment and any other information they may have, personal or otherwise, and release all such parties from any liability which may allegedly arise from furnishing such information to NWFHN including, but not limited to, any liability for defamation or invasion of privacy. If I am offered employment by NWFHN I understand that such an offer will be conditioned upon satisfactory results of a background investigation and/or agency medical examination or inquiry, including a drug screen test. If then employed, I understand that I will be required to serve a probationary period. I further understand that my employment and compensation can be terminated, with or without cause or notice, at any time, regardless of the successful completion of my probationary period, at the option of either my employer or myself. I understand that no supervisor or other employer representative other than the CEO has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.

I further understand and voluntarily agree as a condition of employment or my continued employment, that I may be requested by NWFHN to submit to a urinalysis or other drug screen test and that my failure to take such test(s) when requested to do so or unsatisfactory test results will disqualify me from consideration for employment, or if I am then employed, may result in my immediate dismissal.

I certify that I have read, understand, and agree with the above.

Please type your name below confirming that you agree to the above conditions.(Required)

Date(Required)

Month

Day

Year