Trillium Health

JOB INTEREST

Position Applied for:

I Prefer Full time Part time Temp PRN Day Shift Evening Shift Night Shift

Date Available

Salary Desired

PERSONAL INFORMATION

FULL NAME

Date

First Name

Middle Name

Last Name

Date

ADDRESS

Street Address

Apt/Suite

City

State

Zip Code

Phone Number

Social Security Number(SSN)

PREVIOUS APPLICATIONS

Have you ever applied for a position with trillium behavioral health Before? Yes No

Have you applied within the last 6 months? Yes No

If yes, give the date(s)

How were you referred to us?

Advertisement: (Publication)

Employee: (Name)

Have you previously been employed by trillium behavioral health? Yes No

If yes, When?

Name worked under, if different

GENERAL INFORMATION

Are you able to perform the essential functions of the position for which You are applying, either with or without reasonable accommodation(s)? Yes No

(Job description is available for your review with Human Resources Dept.)

If necessary, please describe what type(s) of reasonable accommodation(s) is/are needed:

AGE IF UNDER 18

(Upon hiring, you will be required to submit proof of age if under 18 and you will be required to have a valid work permit.)

Date of Birth

If offered employment, can you submit verification of your legal right to work in the united states? Yes No

Are you related to any present employee of trillium behavioral health? Yes No

If yes, who?

Relationship

MILITARY INFORMATION

Were you ever in the military? Yes No

If yes, what branch?

what rank attained?

SPECIAL SKILLS and TRAINING

This information is only taken into consideration to the extent that it is relevant

Specify number of months/years of experience and/or speed

Experienced on a hospital computer system? Yes No

Describe

Word processing (speed)

Date last tested

Software used

Spreadsheet (software used)

10 KEY (touch) Yes No

PBX (Type Board)

TYPING (Speed)

Date last tested

PROFESSIONAL LICENSES / REGISTRATIONS / CERTIFICATIONS

Type

Number

State Issued

Date Issued

Expires On

Has your professional license ever been revoked or suspended? Yes No

If yes, why?

EDUCATIONAL RECORD

School

High School

Address

Years Attended

Major Field of Study

Degre Awarded

Vocational

College

Additional coursework or education you wish to be considered

Please list specific skills, training, experience and qualifications relevant to the position for which you have applied

EMPLOYMENT HISTORY

(Most recent employer first - explain lapses in employment between jobs)

Employer

(Include Address and Contact Number)

Name & Title

Dates Of Employment

Supervisor’s Name & Title

Reason Of Leaving

REFERENCES

Please provide three (3) professional references

Name & Title

Address

Phone & Email

Years Known

ADDITIONAL INFORMATION

Please provide any additional information you would like us to consider in your application for employment at trillium health

Application for Employment

AN EQUAL OPPORTUNITY EMPLOYER

Apply Online