Online Job Application Form

Please fill in the following form as completely as possible. This will allow us to better process your application quickly and accurately. If you prefer not to send this form via the internet, you can alternatively download the PDF version of the application form.

Personal Information
First Name
Last Name
Middle Initial
Address
City
State
Zip Code
Phone Number
E-mail
Shifts Available
Days
Evenings
Nights
Weekends
Full Time
Part Time
Date Available to Start
Salary Desired
Area Desired	BrainerdDuluthElyFaribaultGrand RapidsRochesterTwin CitiesVirginiaWillmar
Position Applying For
I am currently employed
If so, may we inquire of your employer?
Yes
No
How did you learn about this position?
Education Information
High School
Location
Date Graduated
College/ Professional/ Trade
Location
Major Course
Degree Received
Other Including Military
Location
Major Course
Degree Received
Honors/Activities
Professional Registration (if applicable)
Other States Currently or Forerly Registered
References (other than relatives)
Reference 1
Name
Address
Phone
Relationship to You
Reference 2
Name
Address
Phone
Relationship to You
Reference 3
Name
Address
Phone
Relationship to You
Present/Former Employers
Most Recent Employer
Company Name
Address
Phone
Start Date
End Date
Starting Salary
Ending Salary
Name of Supervisor
Supervisor Phone
Supervisor Fax
Job Title
Duties/Responsibilities
Reason for Leaving
Second Most Recent Employer
Company Name
Address
Phone
Start Date
End Date
Starting Salary
Ending Salary
Name of Supervisor
Supervisor Phone
Supervisor Fax
Job Title
Duties/Responsibilities
Reason for Leaving
Third Most Recent Employer
Company Name
Address
Phone
Start Date
End Date
Starting Salary
Ending Salary
Name of Supervisor
Supervisor Phone
Supervisor Fax
Job Title
Duties/Responsibilities
Reason for Leaving
We may contact the employers listed above unless you indicate those you do not want
Do not contact
Reason not to contact
I hereby authorize investigation of all statements contained in this application, and agree that any misrepresentation made may result in termination of employment offered based on this application. If so terminated, I understand it may be immediate and without obligation or liability. By submitting this application below, I release Spectrum Community Health, Inc. from any liability that may occur and give complete, informed consent for their inquiries into any former employers, educational institutions and/or references. If no contact has been received by either parties, this application will expire in 90 days from the submission date. By submitting this application, I hereby acknowledge that I have read and understand the above.
I agree*