Employment application ⋆ Phoenix LLC

Welcome
About Phoenix
Services
Patients & Families

Menu

Welcome
About Phoenix
Services
Patients & Families

An Equal Opportunity Employer

Phoenix, LLC, is an equal opportunity employer.

This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state or federal law. Applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the organization.

Applicant name*

First

Last

Your email address*

Your address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Phone number

Date of Birth

day

-

month

-

year

Social Security Number

How were you referred to Phoenix, LLC?

Next

Position applying for

Do you meet the criteria for the position that you are applying for?

Yes

No

Are you applying for

Full time work

Part time work

What days and hours are you available for work?

Are you applying for temporary work, such as summer or holiday work?

Yes

No

If applying for temporary work, when will you be available?

If hired, when can you start working?

Can you work on the weekends?

Yes

No

Can you work evenings?

Yes

No

Can you work overtime?

Yes

No

Annual salary desired

Previous

Next

Have you ever applied or worked for Phoenix, LLC before?*

Yes

No

If yes, explain (include dates)

Do you have any friends, relatives or aquaintances that work for Phoenix, LLC?

Yes

No

If yes, state their name and relationship

If hired, would you have reliable transportation to and from work?

Yes

No

Are you over the age of 18? (If under 18, hire is subject to verification of miniumum legal age)

Yes

No

If hired, would you be able to present evidence of your U.S. Citizenship or proof of your legal right to work in the United States?

Yes

No

If hired, are you willing to submitt o and pass a controlled substance test?

Yes

No

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accomodation?

Yes

No

If no, describe the function(s) that cannot be performed

(Note: Company complies with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.

It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.)

Have you ever been convicted of a criminal offense (felony or misdemeanor) including traffic violations?

Yes

No

If yes, please describe the crime, state the nature of the crime(s) and when and where convicted and disposition of the case.

No applicant will be denied employment solely on the grounds of conviction of a criminal offense.

The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

High School name

High School address

Street Address City State / Province / Region

Did you graduate high school?

Yes

No

Number of years of high school completed

Degree or diploma earned

College / University name

College / University address

Street Address City State / Province / Region

Did you graduate your college / university?

Yes

No

College / University years completed

Degree

Second College / University name

Second College / University address

Street Address City State / Province / Region

Did you graduate from your second college / university?

Yes

No

Second College / University years completed

Degree

Name of vocational school

Vocational school address

Street Address City State / Province / Region Postal / Zip Code

Did you graduate from your vocational school?

Yes

No

Number of years completed of vocational school

Degree

Branch of military served

Current rank or rank at discharge

Years of service

Skills / duties performed

Related details

If you served in the military, thank you for your service.

Do you speak, write or understand any foreign languages?

Yes

No

If yes, describe which language(s) and how fluent of a speaker you consider yourself to be

Do you have any other experience, training, qualifications or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with Phoenix, LLC?

Yes

No

If yes, please explain

Are you currently employed?

Yes

No

If currently employed, may we contact your current employer?

Yes

No

Below, please describe your past and present employment positions dating back five years.

Please account for all periods of unemployment.

Even if you have attached a resume, this section must be completed.

Name of most recent employer*

Name of most recent supervisor

Phone number of most recent employer

Most recent employer business type

Most recent employer address

Street Address City State / Province / Region

Length of employment (include dates)

Position and duties

Reason for leaving

May we contact this employer for a reference?

Yes

No

Name of employer*

Name of supervisor

Phone number of employer

Employer business type

Employer address

Street Address City State / Province / Region

Length of employment (include dates)

Position and duties

Reason for leaving

May we contact this employer for a reference?

Yes

No

List below three persons who have knowledge of your clinical work performance within the last four years. Please include professional references only.

Reference #1

First

Last

Reference #1 Phone Number

Reference #1 Address

Street Address Street Address Line 2 City State / Province / Region Country

Reference #1 occupation

Number of years known reference #1?

Reference #2

First

Last

Reference #2 Phone Number

Reference #2 Address

Street Address Street Address Line 2 City State / Province / Region Country

Reference #2 occupation

Number of years known reference #2?

Reference #3

First

Last

Reference #3 Phone Number

Reference #3 Address

Street Address Street Address Line 2 City State / Province / Region Country

Reference #3 occupation

Number of years known reference #3?

Please read and initial each paragraph, then sign digitally below.

I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true & correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure can be grounds for rejection of application or, if I am employed by this company, terms for my immediate expulsion from the company *

I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or the company.*

I permit the company to examine my references, record of employment, criminal background, medical history, education record, and any other information required for employment. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers & all other persons, corporations, partnerships & associations from any & all claims, demands or liabilities arising out of or in any way related to such examination or revelation.

By typing your name in the box below, you agree that this is a legal binding electronic signature and everything you entered in the above form is true and the information is correct to the best of your knowledge. You acknowledge this information is being sent electronically to Phoenix, LLC human resources department.*

Todays date

Attach a cover letter

Attach a resume

Contact us

Phone: 540 685 4298

info@phoenixllc.org

Monday – Friday 8:30 – 5:00

Closed Saturday & Sunday

Roanoke Office

4919 Brambleton Avenue

Roanoke, Virginia 24018

P: 540 685 4298

F: 540 685 4299

Rocky Mount Office

235 Claiborne Avenue

Suite #200

Rocky Mount, Virginia 24151

P: 540 238 2080

F: 540 238 2081

© Copyright 2023 Phoenix, LLC. All Rights Reserved | Website developed by SKY6 MEDIA