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Please Answer All Questions. Resumes Are Not A Substitute For A Completed Application.

We are an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed servicemember status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state, or local laws.

THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE.

Name *

First

Last

Email *

Position Applied For *Sleep TechnologistDME Clinician – New Orleans areaCommunity Educator – Baton Rouge area

Phone Number *

Phone Type *Cell Phone with TextingCell Phone | NO TextingLand Line

Alternate Phone Number

Current Street Address (Where you live) *

City, State ZIP *

How long have you lived there? *

Mailing Address (If Different)

Mailing Address – City, State ZIP

Desired Salary / Hourly Rate *

If under the age of 18, can you produce the necessary work certificate at the time of employment? *Not Applicable – I'm 18 or older.YesNo

Type of Employment Desired *Full-TimePart-TImePRN (As Needed)Temporary

Are you willing to work overtime? *YesNo

Date on which you can start work if hired *

Have you ever been employed by this Company? *NoYes

If Yes, provide dates of employment, location, and reason for separation from employment.

If applicable, below list any other names by which you have been known which may be necessary to allow us to confirm your work and educational record. For example, change of name, use of an assumed name, nickname, etc.

High School(s) Name and Location (City, State) *

Number of Years Completed *

Did you graduate high school? *YesI got my GED instead.No

College(s) Name and Location (City, State)

Course of Study / Major

Number of Years Completed

Did you graduate college?YesNo

Type of Degree in what field

i.e. BS in Biology, BA in Marketing, Associate Degree in Business, etc.

Business, Technical, or Trade School or Post College(s) – Name and Location (City, State)

Course of Study / Major

Number of Years Completed

Did you complete the program?YesNo

Degree or Certification

Honors Received

Most Recent Employer *

Employer's Address, City, State *

Type of Business *

Employer's Phone Number *

Dates Employed (start month/year – end month/year) *

If you are still working for this employer, please list start month/year – present

Job Title *

Duties *

Supervisor's Name *

May we contact? *YesNo

If No, why not?

Starting wage / salary *

Ending wage / salary *

Reason for leaving *

What will this employer say was the reason for your employment terminating? *

How much notice did you give when resigning? If none, explain. *

Previous Employer *

The job you had prior to your most recent job.

Employer's Address, City, State *

Type of Business *

Employer's Phone Number *

Dates Employed (start month/year – end month/year) *

Job Title *

Duties *

Supervisor's Name *

May we contact? *YesNo

If No, why not?

Starting wage / salary *

Ending wage / salary *

Reason for leaving *

What will this employer say was the reason your employment terminated? *

How much notice did you give when resigning? If none, explain. *

1. Have you ever been terminated or asked to resign from any job? *NoYes

If Yes, how many times?

2. Has your employment ever been terminated by mutual agreement? *NoYes

If Yes, how many times?

3. Have you ever been given the choice to resign rather than be terminated? *NoYes

If Yes, how many times?

If you answered Yes to any of the above three questions (1. 2. and 3.), please explain the circumstances of each occasion.

Work Related Reference #1 Name *

Please list the names of additional work-related references we may contact. Individuals with no prior work experience may list school or volunteer-related references.

Position *

Company *

Work Relationship *

(i.e., supervisor, coworker)

Reference's Phone Number *

Work Related Reference #2 Name *

Please list the names of additional work-related references we may contact. Individuals with no prior work experience may list school or volunteer-related references.

Position *

Company *

Work Relationship *

(i.e., supervisor, coworker)

Reference's Phone Number *

Personal Reference #1 Name *

Please list the names of personal references (not previous employers or relatives) who know you well that we may contact.

Occupation *

Address, City, State *

Personal Reference #1's Phone Number

Number of years known *

Personal Reference #2 Name *

Please list the names of personal references (not previous employers or relatives) who know you well that we may contact.

Occupation *

Address, City, State *

Personal Reference #2's Phone Number

Number of years known *

The information I have provided is true, accurate, and complete. *

• I attest that the information I have provided is true, accurate, and complete.

My typed name below acts as my signature on this application. *

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