* 1. Full Name

* 2. What CHC location are you applying for?

* 3. What position are you seeking?

* 4. Today's Date

Date / Time

* 5. Phone Number

* 6. Email Address

* 7. Your Address

* 8. Have you ever used another name? If so, please state names and dates:

* 9. Salary:

* 10. When could you start?

* 11. Part Time or Full Time

* 12. If you prefer part time, what days and hours would you be available?

* 13. Do you have a close friend or family member who works at CHC?

* 14. How did you hear about the job you are applying for?

* 15. List 2 people that have known you at least 1 year that we may contact. Do not include relatives, former employers, or personnel of this company.

* 16. Education: High School

* 17. Education: College

* 18. Education: Other

* 19. Military Service

* 20. Work History #1

* 21. Work History #2

* 22. Work History #3

* 23. Work History #4

* 24. May we contact all your employers listed?

* 25. Have you ever been convicted of, pleaded no contest to, or received a suspended imposition of sentence for a felony by any court or law (Federal, State, Military, Local)?

(Note: Conviction for a felony will not necessarily disqualify you from employment with CHC)

* 26. Drivers License

* 27. Is your drivers license currently suspended?

* 28. List any traffic convictions you have had in the last 24 months (required in order to to drive vehicle or equipment)

* 29. Are you legally eligible to work in the United States?
(The law requires you to provide us with proof of authorization for employment in the U.S. within 3 days of your hire date)

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