Job Seekers Apply with Executive Clinical Services, LLC

Postition Information
Position Desired: *
Date Available: *
Type of Employment Desired: *	Part Time Full Time
Personal Information
First Name *
Last Name *
Address *
City *
State	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  Zip *
Telephone *	-
Alternate Telephone *	-
Do you have a valid Driver's License? *	Yes No
Class	CDL? Yes No
Do you have relatives working for Executive Clinical Services? *	Yes No
If yes, Employee's Name
Have you ever served in the military? *	Yes No
Do you speak any other language(s)? Specify *
Do you have the legal right to obtain employment in the United States? *	Yes No
Can you perform the essential functions and responsibilities of the position for which you are applying? *	Yes No
If not, explain
Do you require any special accomodation to perform required duties? *	Yes No
If yes, explain
List any current licenses, certifications, or registrations required for the position for which you are applying. Include date received.
Have you ever been convicted of any criminal or driving offense(s) other than a minor traffic violation? *	Yes No
If yes, written documentation must be provided about criminal offenses from the clerk of court in the county in which the conviction was made, and about any driving offenses other than minor traffic violations from the motor vehicles office.
You must provide at least three current reference letters and/or the name of individuals with whom a reference interview can be conducted. Please give the full name, mailing address, and phone number of three references who have knowledge of your background and qualifications the field. Reference 1 Reference 2 Reference 3
Education & Skills
Level of education completed *
High School GED College 0-3 yrs Associate Degree Bachelor Degree Masters Degree
If degree, specify major
Software Applications *
Typing WPM
Experience List last 5 years of work experience
Start Date * End Date * Beginning Salary * Ending Salary *
Name of Employer: *
May we contact? *	Yes No
Address *
City *
State	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  Zip *
Supervisor Name *
Telephone *	-
Title and Duties Performed *
Reason for Leaving *
Start Date * End Date * Beginning Salary * Ending Salary *
Name of Employer: *
May we contact? *	Yes No
Address *
City *
State	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  Zip *
Supervisor Name *
Telephone *	-
Title and Duties Performed *
Reason for Leaving *
User Information
Email Address * [?]
Password * [?]
Your password must at least 6-16 characters long, and can be any combination of letters and numbers
Re-Type Password *
I agree to carry out the designated responsibilities to the best of my ability. I have read the position description. I am aware there is a conditional period of 3 months prior to permanent employment. I certify that I have given true, accurate and complete information on this form to the best of my knowledge. I authorized investigation of statements made in this application and understand that false information may be grounds for denial of my position and/or dismissal if I am employed.
Date	Signature of Applicant

• Physicians
• Nursing Home Administrators
• Executive Directors
• Director of Clinical Services
• Clinical Services Consultant
• Director of Nursing
• Assistant Director of Nursing
• MDS Coordinators
• Dietary Managers
• Therapists