Name *
First
Last

Street Address *

City,State,Zip *

Primary Phone Number *

Email *

Position Applying For: *

Employment Status Requesting *

Are you at least 18 years old
Yes
No

Have you previously worked at SCH?
Yes
No

Position Held & Dates Position Held

Do you currently have any relatives working at SCH?
Yes
No

Are you currently employed?
Yes
No

If Yes, may we contact your current employer
Yes
No

What date would you be available to start?

Please list High School Attended and year completed

Please List College or University Attended and Degree Received

Please list 3 Professional references below: *
Please include Name, Phone#, and Relationship

Have you ever been convicted of a felony crime? *
Yes
No

If Yes, Please Explain

Please list Employment History in the space provided *
Employer 1: Include Dates, Supervisor's Name, Address, Phone# Position/Job Duties and Reason for leaving.

Please list Employment History in the space provided
Employer 2: Include Dates, Supervisor's Name, Address, Phone# Position/Job Duties and Reason for leaving.

Please list Employment History in the space provided
Employer 3: Include Dates, Supervisor's Name, Address, Phone# Position/Job Duties and Reason for leaving.

Please list any additional skills or experience that would be helpful in the position for which you have applied.

Where did you hear about us?
Social Media
Relative or Friend
Print Advertising (Papers)
Other

SCH employee referral
If referred by a current SCH Employee please list their name here.

I certify with my signature below: That the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination *
Applicant's Signature

Email *

Nurse Practitioner for Rural Health Clinic

Nurse Practitioner for Rural Health Clinic