HCR is an Equal Opportunity Employer and considers applicants for all positions without regard to race, color, age, religion, creed, gender, national origin, disability, sexual orientation, marital or veteran status, or any other legally protected status.
*HCR maintains an Affirmative Action Program.
Fields with an asterisk (*) next to them are required.
Date (mm/dd/yyyy format)
Last Name* First Name* Middle Initial
Street Address City State Zip
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DE
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HI
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IN
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ME
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OH
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OR
PA
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TN
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VA
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WA
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Telephone* #1 #2
SSN
Position Applying For*
How did you hear about us?
Friend
Relative Newspaper
Other
Have you filled out an application with us before?
If yes, when?
Have you worked for us before?
If yes, when?
Are you 18 years of age or older?
Are you currently one of the following?
What hours are you looking for?
Desired Salary Range*
On what date are you available to start working?
Do you have a valid driver’s license?
Do you own a car, and have daily access to it for work?
Can you legally work in the United States?
Have you ever been convicted of any crime (including DWI, alcohol or drug conviction)? **
If yes, state the offense, location, and date
**Criminal convictions are not an absolute bar to employment, but will be a part of specific considerations.
Education and Training Experience
Please state the last grade completed:
Courses studied your final year of education
Name of last school attended
Highest Degree Received
Employment Experience
List your 3 most recent employers beginning with the most recent.
Employer Telephone Dates Employed
From To
Address Position Held
Pay Rates
Supervisor’s Name Starting Ending
Reason for Leaving
May we contact them?
Responsibilities/Duties
Employer Telephone Dates Employed
From To
Address
Position Held Pay Rates
Supervisor’s Name Starting Ending
Reason for Leaving
May we contact them?
Responsibilities/Duties
Employer Telephone Dates Employed
From To
Address
Position Held Pay Rates
Supervisor’s Name Starting Ending
Reason for Leaving
May we contact them?
Responsibilities/Duties
Please explain any gaps in employment.
Describe any specialized apprenticeship, skills and extracurricular activities
Personal References
Please list 3 people that you are not related to.
Name Phone # Years Known Relationship to Reference
Supplemental Employment Information
Please fill out any of the information below that applies to your current credentials.
Professional Licensure (i.e. RN, PT or MSW) License #
Date of Expiration State(s) Issued
Professional Certification or Degree
Special Skills
Clerical
WPM
Technical
List type(s) of software used:
Clinical
Other:
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Applicant's Certification
I hereby certify that the above information is furnished for the purpose of gaining employment, and is true to the best of my knowledge and belief. I understand that such information shall be the basis of my being considered for employment, and that false statements may result in my application not being considered or my dismissal in the event that employment is affected. Authorization is hereby given to HCR to obtain reference checks from any of the named sources in this application and the sources to release information if requested by HCR.
I agree that if I am employed by HCR, I will abide by all the rules and regulations of the company. I understand that the taking of drug and alcohol tests, when given pursuant to company policy, are a condition of continued employment and that refusal to take such tests when asked, will be grounds for my immediate termination. I understand that my employment is “at will,” and may be terminated by HCR or myself at any time for any reason, and with or without prior notice.
By checking here I certify that I understand and agree to the above*
