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THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT but merely is intended to evaluate suitability for employment. It is the policy of the company to provide equal employment to all qualified persons without discrimination on the basis of sex, religion, race, national origin, color, age, pregnancy, disability, military status, military obligations, veteran status, genetic information, citizenship or any other status protected under local, state or federal law. It is also the policy of the company to have the option of conducting pre-employment screening before a job offer is made. If a job offer is made, employment may be contingent upon the successful completion of a pre-employment drug screening and/or medical examination. This application will remain active for 6 months.
Employment Application
Select Posting to Apply for:
Listing Info:
Posted On:
Status:
Department:
Shift:
Location:
Education:
Travel:
Job Description:
Preferred Skills:

Personal Information
First Name: Middle Name: Last Name:
Home Phone: Work Phone: Cell Phone:
Email Address:

Address
Street City State Zip Code Since (Mo/Yr)
Current Address:

Education
School Attended City State Diploma Degree/Cert Area of Study
High School/GED High School Diploma/GED
Undergrad School
Grad School
Other School
Do you have trach care experience? LPN/RN Applicants: Do you have at least 1 year clinical experience?
Please list any professional licenses, designations, certifications, etc. that may relate to the position applied for.
Include date granted, name of organization, and any other relevant information.

Employment Information
Position Applied For: Date You Can Start Desired Salary $
Do You Prefer          Can you work          Shift length  
Available:         I am willing to travel:  
Are you willing to work in the following locations Knox County Roane County Anderson County Hamblen County Jefferson County Claiborne County Loudon County Blount County
Not Available

Please answer all of the following questions.

1. Are you at least 18 years of age and legally eligible to work for our company in the United States?
2. Have you worked for this business before?
If yes, please provide dates and locations.
3. Have you received a description of the job or been made aware of the essential functions of the job you are applying for?
4. Do you understand the job requirements?
If no, please explain.
5. Are you currently bound by a noncompetition, confidentiality or trade secret agreement?
If yes, please explain.

Employment History
Please start with your present or most recent position.
Employer: Position Held:
Start Date: Final Date:
What is your best guess as to how this supervisor would rate your overall performance?
Excellent Very Good Good Fair Poor Impossible to Provide
If impossible to provide, please explain.
What do (did) you like most about your job?
What do (did) you least enjoy?
If you are leaving or have left the company,
please indicate your motivation to leave.
100% Mine Mutual 100% Company's (I was fired) Options don't fit circumstance
If options don't fit circumstance,
please explain.
Reason for Leaving:
May we contact the above listed employer?
If no, why not?

Employer: Position Held:
Start Date: Final Date:
What is your best guess as to how this supervisor would rate your overall performance?
Excellent Very Good Good Fair Poor Impossible to Provide
If impossible to provide, please explain.
What do (did) you like most about your job?
What do (did) you least enjoy?
If you are leaving or have left the company,
please indicate your motivation to leave.
100% Mine Mutual 100% Company's (I was fired) Options don't fit circumstance
If options don't fit circumstance,
please explain.
Reason for Leaving:
May we contact the above listed employer?
If no, why not?

Employer: Position Held:
Start Date: Final Date:
What is your best guess as to how this supervisor would rate your overall performance?
Excellent Very Good Good Fair Poor Impossible to Provide
If impossible to provide, please explain.
What do (did) you like most about your job?
What do (did) you least enjoy?
If you are leaving or have left the company,
please indicate your motivation to leave.
100% Mine Mutual 100% Company's (I was fired) Options don't fit circumstance
If options don't fit circumstance,
please explain.
Reason for Leaving:
May we contact the above listed employer?
If no, why not?

Self-Appraisal
What qualifications, abilities, and strong points will help you succeed in this position?
Please use this space to list any special skills you may have that relate to the position applied for.
What are your weak points and areas for improvement?
How do you rate your patient care skills on a scale of 1-10, with 10 being perfect?
Why?

How do you rate your communication skills on a scale of 1-10, with 10 being perfect?
Why?


Ratings by Supervisors
If you were to be asked to arrange calls with bosses you've had in the past 8 years, what is your best guess as to how they would rate you?
The rating scale is: 5 = Excellent, 4 = Very Good, 3 = Good, 2 = Fair, 1 = Poor, for the following:
InitiativeReliabilityJob Knowledge
CommunicationProfessionalism

Motor Vehicle-Related Questions
Please answer the following questions if the position you are applying for requires driving a motor vehicle.
1. Do you have a valid driver's license?
If yes, Driver's License Number Date of Issue
2. Have you been convicted of or pled guilty to any traffic-related offense within the past five years?
If yes, please explain
3. Have you had your driver's license suspended or revoked or had your driving privileges modified by a court of law?
If yes, please explain
4. Please list all states from which you hold or held a driver's license
5. Do you have proof of liability automobile insurance?

References
Three references are required, two references must be professional.
Name Email Address Phone Number Relationship Years Known
Reference 1
Reference 2
Reference 3
Reference 4


Resume (Upload)
Upload a copy of your Resume here.
NOTE: Only PDFs, and Word Documents are supported.

Applicant Certification Agreement
1. The company and other persons or employers are released from all liability brought forth by any investigation resulting from my submission of this electronic application and the data contained herein.
2. The information in this application is true and complete to the best of my knowledge. Any falsification, misrepresentation, or omission on this application can be cause for denial or termination of employment.
3. If hired, my employment is voluntary, meaning that either party can end employment at any time for any reason. Upon acceptance of employment if a position is offered, I agree to abide by all existing and future company rules and regulations. The company reserves the right to change any working agreement as deemed necessary.
4. Any employment offer is contingent upon my providing proof of identity and eligibility to work in the country of employ, clear background screening and proof of current licensure and/or certification.
5. I have read and reviewed the information provided in this application and the above statements. By signing this application for employment I certify that I understand all parts of it and have answered all questions completely and fully.
6. I understand that by typing my name in the signature box below and submitting this application electronically, I authorize Camellia Healthcare to perform background investigations including driving record, reference checks and licensure verifications.
7. Camellia Healthcare hereby discloses to employee or prospective employee (“Employee”) that it may obtain from third parties information concerning Employee. Such information may include that which is obtained through reference checks with Employee's past employers, co-workers, and associates. Camellia Healthcare will use this information for employment purposes only.

Security Code

Signature
Type Name in Signature Box
NOTICE: If you experience any technical difficulty submitting this application please contact the Camellia IT Department at 601-264-4860 (M-F 8am - 5pm CST).