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Employment Application



  • Careers at Ohio Hills Health Centers:


  • Position Applying For: *




  • Best time to contact you:




  • How Did You Learn About Us?:






  • Employment Eligibility:


  • Are you of legal age to work?: *



  • Do you have any physical or mental limitations which could affect your ability to perform the job for which you have applied?: *



  • Have you ever been employed with us before?: *




  • Were you referred?:



  • If yes, by who?:

  • Are you currently employed?: *



  • Are you legally allowed to work in the United States?: *



  • On what date would you be available to begin work?: *

  • Are you available to work (check all that apply): *




  • Have you ever been convicted of a felony or misdemeanor?: *



  • If yes, explain: *

  • Upload Resume:


  • If you have a detailed resume, you may submit it without filling out the information below. By filling out this form or submitting a resume, you are agreeing that all information provided is correct.

  • Apply with a resume:
    (Acceptable Formats: .pdf, .doc, .docx, .xlsx, .png, .jpg, .jpeg, .gif, .tiff)

  • Education:


  • High School:



  • School name:

  • Did you graduate?:



  • College/Trade School:



  • School name:


  • Course of study:

  • Degree:

  • Did you graduate?:



  • Graduate School:



  • School name:


  • Course of study:

  • Degree:

  • Did you graduate?:



  • Additional Education:



  • School name:


  • Course of study:

  • Degree:

  • Did you graduate?:



  • Current/Recent Employer:


  • Starting with your present or most recent job, include any job-related assignments or activities (ex: military, volunteering, etc.). You may exclude organizations which include race, color, religion, gender, national origin, disabilities, or other protected status.

  • Employer name:

  • Job title:


  • Phone:

  • Supervisor's Full Name:

  • Reason for leaving:

  • If still employed, use current date as end date.


  • Starting wage:

  • Work duties:

  • May we contact this employer?:



  • Past Employer:


  • Employer name:

  • Job title:


  • Phone:

  • Supervisor's Name:

  • Reason for leaving:

  • Time employed (months or years):

  • Starting wage:

  • Work duties:

  • May we contact this employer?:



  • Additional Information:


  • Include any training, qualifications, skills (including computer programs), or experience acquired from your previous employment.

  • List here:

  • Professional References:


  • The references below must include individuals from the same professional discipline that have trained with you or worked with you during your career (ex: Nurse/MA, NP, PA, Physician, Dentist, etc.).

  • 1)

  • Full name:

  • Phone:

  • Email:

  • Occupation:

  • 2)

  • Full name:

  • Phone:

  • Email:

  • Occupation:

  • Applicant's Statement::


  • I certify that all the information submitted by me on this application is true and complete. I understand that, if any false information, omissions, or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time.

  • Digital Signature:


  • By entering your full name here, you are agreeing to the disclaimer above: *

  • Date: *


* = Required