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* 1. Full Name

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* 2. What CHC location are you applying for?

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* 3. What position are you seeking?

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* 4. Today's Date

Date / Time

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* 5. Phone Number

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* 6. Email Address

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* 7. Your Address

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

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* 9. Salary:

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* 10. When could you start?

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* 11. Part Time or Full Time

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

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

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

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* 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.

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* 16. Education: High School

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* 17. Education: College

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* 18. Education: Other

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* 19. Military Service

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* 20. Work History #1

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* 21. Work History #2

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* 22. Work History #3

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* 23. Work History #4

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* 24. May we contact all your employers listed?

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* 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)

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* 26. Drivers License

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* 27. Is your drivers license currently suspended?

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

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* 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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