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We are an equal employment opportunity employer.  We adhere to a policy of making employment decisions without regard to race, color, age, sex, sexual orientation, religion, national origin, genetic information, disability, veteran status, citizenship status, marital status or any other status protected by law.  We assure you that your opportunity for employment with us depends solely upon your qualifications.

Personal Information

Legal Name*
Address*
Have you ever worked for Avant Healthcare Professionals? *
Have you ever been involuntarily terminated or requested to resign?*
Are you legally eligible to work in the United States?*
If hired, can you provide verification of your legal right to work in the United States?*
Will you now or in the future require sponsorship to be able to work in the United States?*
Are you at least 18 years of age?*
If required for the position, do you have a valid driver's license?*
Have you ever worked under a different name?*
Are you able to perform the essential functions of the position as listed and described on the attached job description or as demonstrated by the company representative with or without a reasonable accommodation?*
Do you have a non-compete agreement or are you subject to any restrictive covenant with any of your former employers?*
Copy of Non-complete*
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Do you have any relatives and/or friends employed at Avant Healthcare Professionals? If yes, please enter the names of your relatives/friends.*

Voluntary Self-Identification

We are an Affirmative Action, Equal Opportunity Employer. Our employment decisions are made without regard to race, color, religion, gender, national origin, age, disability, marital status, veteran or military status, or any other legally protected status. The purpose of this Employee EEO Self-Identification Form is to comply with federal government record-keeping and reporting requirements. Periodic reports are made to the government on the following information. The data you provide on this form will be kept confidential and used solely for analytical and reporting requirement purposes. This form is processed and maintained separately from your personnel file and is not used to make decisions about the terms and conditions of employment. Completion of this form is optional and voluntary. We appreciate your assistance.

Race

Veteran Status

I belong to the following classifications of protected veterans (choose all that apply):

Disability Status

Disabilities include, but are not limited to:
Blindness -- Autism -- Bipolar disorder -- Post-traumatic stress disorder (PTSD)
Deafness -- Cerebral palsy -- Major depression -- Obsessive compulsive disorder
Cancer -- HIV/AIDS -- Multiple sclerosis (MS) -- Impairments requiring the use of a wheelchair
Diabetes -- Epilepsy -- Schizophrenia -- Muscular dystrophy
Missing limbs or partially missing limbs -- Intellectual disability (previously called mental retardation)

Employment Details

Date Available*
$

Resume & Cover Letter

Resume*
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Cover Letter
No File Chosen
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Education

High School

High School Name
Course of Study
Years Completed
Did you graduate?

College

College Name
Course of Study
Years Completed
Did you graduate?
Degree

Post Graduate

Grad School Name
Course of Study
Course of Study
Did you graduate?
Degree

Business/Trade/Technical

Name of School
Course of Study
Years Completed
Did you graduate?
Degree/Diploma
Certifications

Most Recent Employer

Employer*
Job Title*
Start Date*
End Date
Type of Business*
Still Employed*
Ok to contact?*
Starting Salary*
Salary Type*
Ending Salary*
Salary Type*
Briefly state your responsibilties*
Reason for Leaving*
Job Description*
What major challenges did you face in this role?*
What were your successes/accomplishments?*
Most enjoyable part of this job?*
Least enjoyable part of this job?*
Supervisor's Name*
Supervisor's Title*
Supervisor's Phone*
Supervisor's Email*

Previous Employer

Employer
Job Title
Start Date
End Date
Type of Business
Starting Salary
Salary Type
Ending Salary
Salary Type
Briefly state your responsibilties
Reason for Leaving
Job Description
What major challenges did you face in this role?
What were your successes/accomplishments?
Most enjoyable part of this job?
Least enjoyable part of this job?
Supervisor's Name
Supervisor's Title
Supervisor's Phone
Supervisor's Email

Previous Employer

Employer
Job Title
Start Date
End Date
Type of Business
Starting Salary
Salary Type
Ending Salary
Salary Type
Briefly state your responsibilties
Reason for Leaving
Job Description
What major challenges did you face in this role?
What were your successes/accomplishments?
Most enjoyable part of this job?
Least enjoyable part of this job?
Supervisor's Name
Supervisor's Title
Supervisor's Phone
Supervisor's Email

Previous Employer

Employer
Job Title
Start Date
End Date
Type of Business
Starting Salary
Salary Type
Ending Salary
Salary Type
Briefly state your responsibilties
Reason for Leaving
Job Description
What major challenges did you face in this role?
What were your successes/accomplishments?
Most enjoyable part of this job?
Least enjoyable part of this job?
Supervisor's Name
Supervisor's Title
Supervisor's Phone
Supervisor's Email

Previous Employer

Employer
Job Title
Start Date
End Date
Type of Business
Starting Salary
Salary Type
Ending Salary
Salary Type
Briefly state your responsibilties
Reason for Leaving
Job Description
What major challenges did you face in this role?
What were your successes/accomplishments?
Most enjoyable part of this job?
Least enjoyable part of this job?
Supervisor's Name
Supervisor's Title
Supervisor's Phone
Supervisor's Email

References

Minimum of 3 references required

Reference 1*

Title
Company
Choose One
Phone
Email

Reference 2*

Title
Company
Choose One
Phone
Email

Reference 3*

Title
Company
Choose One
Phone
Email

Reference 4

Title
Company
Choose One
Phone
Email

Reference 5

Title
Company
Choose One
Phone
Email

Acknowledgements

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