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Personal Information

First Choice

Second Choice

High School


Vocational Training if applicable


Professional Licenses and/or Certifications

List current (or most recent) employer first and all others in reverse chronological order

References list three references who are not relatives or form employers

Please indicate Days and Hours you are available for work

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

I understand that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as if directed by my department head or administrator of this institution


I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for eliminations from consideration for employment, or termination after employment if discovered at a later date. I authorize Solid Rock Health Educators, LLC to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. If requested, I agree to submit to a physical exam, criminal and credit background investigation, and/or screening for illegal substances upon conditional offer of employment. I understand that this document is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract for guaranteed employment. I understand that staff employee of Solid Rock Health Educators, LLC serve at-will, and the employment relationship may be terminated at any time by either party, or any or no reason, other than a reason prohibited by law. If employed, I will be required to furnish proof of eligibility to work in the United State, to file State security questionnaire and State loyalty oath, and to comply with company and departmental regulations. I understand that if employed on a temporary basis, I would be paid for hours worked only, and would be ineligible for benefits including paid time off. I understand that first ninety days of regular employment represent a provisional period, during which I would not be eligible to apply for unemployment benefits and during which I may be terminated without right to appeal.

Select a country first.