Oxford HealthCare
 


STEP 1: Application for Employment

Applicant Note: Oxford HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without discrimination because of sex, marital status, race, age, creed, national origin, disability or veteran status. This application form is intended for use in evaluating your qualifications for employment. It is not an employment contract. Testing of job-related skills and a drug and alcohol screen will be required prior to employment. Depending on company policy or the needs of the position, an examination by a medical professional may be required.

* Indicates a required field.


*Position Applied For:

Applicant's Name
*Last Name *First Name Middle Name

Maiden Name or Other Names Known By
Last Name First Name Middle Name

*Address *City *County *State *Zip Code

E-Mail Address *Telephone Number *Social Security Number

*Are you either a U.S. citizen or an alien authorized to work in the U.S.?
Yes
No

Have you ever applied before at:
*Oxford HealthCare? Yes No
*Cox Health or Affiliates? Yes No

Have you ever been employed at:
*Oxford HelathCare? Yes No
*Cox Health? Yes No
*Upjohn HealthCare Services? Yes No

*Have you ever plead guilty to, received a suspended imposition of sentence ("SIS") for, or been convicted of an ordinance violation, misdemeanor or felony? Yes No
If yes, please explain:
(A guilty plea, SIS, or conviction record will not automatically disqualify you from consideration. Such factors as the length of time since the offense, seriousness and nature of the violation, and rehabilitation will be taken into account).

Education Information

*Education : Indicate Highest Grade Completed
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 16+

 
Name
Address
Degree/Major
High School
College
Other

Please complete the information for any license or certifiacte you hold (i.e. RN, LPN, CNA, etc.)
Type of License State of License Certificate/License # Expiration Date
Drivers License Info

List last 3 employers beginning with the most recent. We will make every effort to contact previous employers, therefore the correct telephone numbers for past employers is critical.

Current or Last Employer Phone (Include Area Code)
Address City State Zip
Name Used While Employed Job Title Salary
Dates Worked
From: To:
Nature of Work Supervisor
Reason For Leaving

Previous Employer Phone (Include Area Code)
Address City State Zip
Name Used While Employed Job Title Salary
Dates Worked
From: To:
Nature of Work Supervisor
Reason For Leaving

Previous Employer Phone (Include Area Code)
Address City State Zip
Name Used While Employed Job Title Salary
Dates Worked
From: To:
Nature of Work Supervisor
Reason For Leaving

Personal References - Not Family Related

Name
Address City State Zip
Relationship (Friend, Minister, etc.)
Years Known Phone (Include Are Code)

Name
Address City State Zip
Relationship (Friend, Minister, etc.)
Years Known Phone (Include Are Code)

List other experience related to job applying for (paid or unpaid): (133 Characters Max)

Comments: (117 Characters Max)


 

  

      

 
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