HGI Healthcare

Online Employment Application

Personal Information
Last Name
Middle Name
First Name
Other names you are known by?
Are you less than 18 years of age? Yes No (HGI is required to comply with federal, state or provincial law.)
U.S Applicant Only: Are you legally eligible for employment in the U.S.? Yes No (proof of U.S. citizenship or immigration status will be required if hired for a position in the U.S.)
Have you ever been convicted of a criminal offense (felony or misdemeanor)? Yes No If yes, please explain below.
Contact Information
Present Address
City
State/Province
Zip Code/Postal Code
Phone Number Daytime
Phone Number Evening
Mobile Phone
Email
EMPLOYMENT DESIRED
Position:
Location/Department:
Date You Can Start:
Have you ever worked for an Executive Search or Recruiting firm? Yes No
If Yes, which company & when?
EDUCATION
High School
Name
Address
Did you Graduate?	Yes No
Subjects Studied & Degree Received
College
Name
Address
Did you Graduate?	Yes No
Subjects Studied & Degree Received
Post College
Name
Address
Did you Graduate?	Yes No
Subjects Studied & Degree Received
Trade or Business School
Name
Address
Did you Graduate?	Yes No
Subjects Studied & Degree Received
CURRENT & FORMER EMPLOYERS
List below current and last three employers, starting with most recent one first. Please include any nonaid/ volunteer experience that is related to the job for which you are applying. Please complete even if you sent a resume seperately.
EMPLOYER 1:
Current Employer Name
Current Employer Address
Type of Business
Employment Date From
Employment Date To
Duties Performed
Position
Reason For Leaving
Salary or Hourly	Salary Hourly
Starting At:
Current:
If hourly, average # of hours per week
Supervisor's Name
Supervisor's Phone
May We Contact:	Yes No
EMPLOYER 2:
Previous Employer Name
Previous Employer Address
Type of Business
Employment Date From
Employment Date To
Duties Performed
Position
Reason For Leaving
Salary or Hourly	Salary Hourly
Starting At:
Current:
If hourly, average # of hours per week
Supervisor's Name
Supervisor's Phone
May We Contact:	Yes No
EMPLOYER 3:
Previous Employer Name
Previous Employer Address
Type of Business
Employment Date From
Employment Date To
Duties Performed
Position
Reason For Leaving
Salary or Hourly	Salary Hourly
Starting At:
Current:
If hourly, average # of hours per week
Supervisor's Name
Supervisor's Phone
May We Contact:	Yes No
EMPLOYER 4:
Previous Employer Name
Previous Employer Address
Type of Business
Employment Date From
Employment Date To
Duties Performed
Position
Reason For Leaving
Salary or Hourly	Salary Hourly
Starting At:
Current:
If hourly, average # of hours per week
Supervisor's Name
Supervisor's Phone
May We Contact:	Yes No
REFERENCES
Reference 1:
Name
Company
Business Type
Phone
Relationship
Years Acquainted
Reference 2:
Name
Company
Business Type
Phone
Relationship
Years Acquainted
Reference 3:
Name
Company
Business Type
Phone
Relationship
Years Acquainted
I hereby authorize HGI Healthcare to thoroughly investigate my background, references, employment record and other matters related to my suitability for employment. I authorize persons, schools, my current employer (if applicable), and previous employers and organizations contacted by HGI to provide any relevant information regarding my current and/or previous employment and I release all persons, schools, employers of any and all claims for providing such information. I understand that misrepresentation or omission of facts may result in rejection of this application, or if hired, discipline up to and including dismissal. I understand that I may be required to sign a confidentiality and/or non-compete agreement, should I become an employee of HGI, Inc. I understand that nothing contained in this application, or conveyed during any, interview which may be granted, is intended to create an employment contract. I understand that filling out this form does not indicate there is a position open and does not obligate HGI to hire me. Should an employment offer be made, I agree that I maybe required to take a drug test, prior to and possibly during employment, as a condition of that employment. (U.S. APPLICANTS ONLY: I understand and agree that my employment is at will, which means that it is for no specified period and may be terminated by me or HGI at any time without prior notice for any reason. MARYLAND APPLICANTS ONLY: Under Maryland law, an employer may not require or demand, as a condition of employment, prospective employment, or continued employment, that an individual submit to or take, a lie detector or similar test. An employer who violates this law is guilty of misdemeanor and subject to a fine not exceeding $100. MASSACHUSETTS APPLICANTS ONLY: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.)
By Checking this box, you agree to the conditions mentioned above: I Agree
HGI HEALTHCARE IS AN EQUAL OPPORTUNITY EMPLOYER COMMITTED TO HIRING A DIVERSE WORKFORCE

Emergency Contact Information
Emergency Contact 1
Name
Daytime Phone
Evening Phone
Relationship
Emergency Contact 2
Name
Daytime Phone
Evening Phone
Relationship
MEDICAL AND DENTAL INSURANCE
Last Name
First Name
Middle Initial
I am applying for Medical and Dental Insurance from BCBS of NC for:	Myself My Spouse My Children
I have been given the opportunity to apply for enrollment in the Insurance Plan provided by my employer. I have not been induced or pressured by my employer, the agent or the Insurance Carrier to accept or decline coverage. The benefits have been explained to me and after serious consideration; I have decided to take or not to take advantage of this offer for myself and/or my dependent(s).
By checking this box you acknowledge that you have read and understood the information above: I Agree

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