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you are applying for:
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ARNP
Front Desk Representative
Intern
TFS Therapist
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Your Personal Data
Are you at least 18 years old?
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Yes
No
If
not, state your age for
Are there any days, shifts or hours you will not work?
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Yes
No
If
Yes, please explain:
Will you work overtime if required?
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Yes
No
When will you be able to start work?
Have you ever been convicted of a felony or do you have any
pending arrests or convictions?
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Yes
No
(A conviction will not necessarily disqualify you)
If Yes, please explain
Can you, within 3 days of employment,
submit documentation verifying that you are legally eligible
to work in the United States?
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Yes
No
Have you taken any illegal drugs in the last 30 days?
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Yes
No
How did you learn of our company?
Have you ever applied or worked at Suncoast before?
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Previously Applied
Previous Employee
Neither
If Yes, please provide dates:
List any relatives or friends currently employed at Suncoast
Center:
Company Name:
Company Address:
Telephone:
Name of Supervisor:
Dates Employed:
From: (mo/yr)
Hourly/Annual Pay:
Ending Salary:
Job Title(s) Held at This Employer:
Description of Job Duties:
Reason for Leaving:
Company Name:
Company Address:
Telephone:
Name of Supervisor:
Dates Employed:
From: (mo/yr)
Hourly/Annual Pay:
Ending Salary:
Job Title(s) Held at This Employer:
Description of Job Duties:
Reason for Leaving:
Company Name:
Company Address:
Telephone:
Name of Supervisor:
Dates Employed:
From: (mo/yr)
Hourly/Annual Pay:
Ending Salary:
Job Title(s) Held at This Employer:
Description of Job Duties:
Reason for Leaving:
Company Name:
Company Address:
Telephone:
Name of Supervisor:
Dates Employed:
From: (mo/yr)
Hourly/Annual Pay:
Ending Salary:
Job Title(s) Held at This Employer:
Description of Job Duties:
Reason for Leaving:
Please explain any gaps in your employment history:
List any work-related skills, training or experience
you believe are relevant to the job applied for:
Have you ever been discharged or forced to resign?
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Yes
No
If you answered yes above please explain:
Did you receive any discipline in the last 12 months of
active employment?
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Yes
No
If you answered yes above please explain:
Were you given a performance evaluation within the past 12
months of active employment?
Select
Yes
No
If you answered yes above, what was the range of scores used
and what was your score?
Have you ever signed any non-compete agreement with any
other employer that would restrict you from working with
this company?
Select
Yes
No
If you answered yes above please explain:
(may or may not be considered
depending on job applied for)
Describe any
educational degrees, skills training or experience you
believe are relevant to the job applied for:
(Complete this section only if
you served in the military)
Branch of Service:
Dates of Service:
From: (mo/yr)
Rank at Discharge:
Date of Discharge:
Were you honorably discharged?
-
Yes
No
Describe any
military skills training or experience you believe are
relevant to the job applied for:
(may or may not be considered
depending on job applied for)
Do you have a valid Florida Driver's License?
Select
Yes
No
Have you had any moving violations in the past 5 years?
Select
Yes
No
If you answered yes above please explain:
Have you had any DUI or DWI convictions?
Select
Yes
No
If you answered yes above please explain:
Do you have a reliable form of transportation to work?
Select
Yes
No
Referral Source for this position:
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Employment Agency
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Florida Career Link
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Applications
are considered for all positions, and employees are treated
during employment without regard to race, color, religion,
sex, national origin, age, sexual orientation, marital or
veteran status, medical condition or handicap.
Government agencies require periodic reports on
the sex, ethnicity, handicapped and veteran status of
applicants. This data is for analysis and affirmative action
only. Submission of the following information is voluntary:
Sex:
No Answer
Female
Male
Race/Ethnic Group:
No Answer
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Pacific Islander/Native Hawaiian
Two or More Races
White
Select Veteran/Handicap:
None
Vietnam Era Veteran
Disabled Veteran
Handicapped Individual
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version of your resume in the field below (1200 characters
max):
I certify that the answers given herein
are true and complete to the best of my knowledge. I
understand that any misrepresentations, omissions of facts
or incomplete answers in any application document will
disqualify me from further consideration for employment. I
further understand that, if employed, any misrepresentations
or omissions of facts in any application document will be
cause for my dismissal at any time without prior notice.
Suncoast Center regularly conducts background checks.
Enter your full
name here as your electronic signature:
