Name *

First Name

Last Name

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Location *

Location for position you are applying for

ATHC-Winsted

Hutchinson/ATHC-West

Have you applied with us before? *

Yes

No

Are you 18 years of age or older?

Yes

No

Have you ever been employed with ATHC before?

Yes

No

Do any of your friends or relatives, other than spouse, work here?

Yes

No

Are you currently employed?

Yes

No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? *

Proof of citizenship or immigration status will be required upon employment

Yes

No

Are you currently on “lay-off” status and subject to recall? *

Yes

No

Date available for work *

MM

DD

YYYY

Are you available to work:

Full Time

Part Time

Temporary

High School Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Undergraduate College Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Graduate/Professional Education Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone *

(###)

###

####

Name of Supervisor *

First Name

Last Name

Dates Employed:

Start Date

MM

DD

YYYY

Dates Employed:

End Date (If still working here, please keep blank)

MM

DD

YYYY

May we contact?

Yes

No

Employer Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone *

(###)

###

####

Name of Supervisor *

First Name

Last Name

Dates Employed:

Start Date

MM

DD

YYYY

Dates Employed:

End Date (If still working here, please keep blank)

MM

DD

YYYY

May we contact?

Yes

No

Employer Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone *

(###)

###

####

Name of Supervisor *

First Name

Last Name

Dates Employed:

Start Date

MM

DD

YYYY

Dates Employed:

End Date (If still working here, please keep blank)

MM

DD

YYYY

May we contact?

Yes

No

Name Of Reference

First Name

Last Name

Phone Of Reference

(###)

###

####

Name Of Reference

First Name

Last Name

Phone Of Reference

(###)

###

####

Name Of Reference

First Name

Last Name

Phone Of Reference

(###)

###

####

Name *

You are agreeing with the statement above.

First Name

Last Name

Today's Date

MM

DD

YYYY