Application

ARROWHEAD WEST, INC.

Arrowhead West, Inc. is an Equal Opportunity Employer. Qualified applicant will be considered without regard to race, color, religion, gender, sexual orientation, gender identity, age, disability status, ancestry, national origin, political affiliation, genetic information, or marital status.
Today Date

Month Day Year
Full Name *

First Name Middle Name Last Name
Current Address *

Street Address

Street Address Line 2

City State

Zip Code
Email Address
Home Phone Number
Cell Phone Number
Position Applied For *
Start date *

Month Day Year
EDUCATION
High School/GED Name
High School/GED Location
High School Diploma/Degree

Yes No GED
Trade School Name
Trade School Location
Trade School Diploma/Degree

Yes No
Trade School Major
College 1 Name
College 1 Location
College 1 Diploma/Degree

Yes No
College 1 Major
College 2 Name
College 2 Location
College 2 Diploma/Degree

Yes No
College 2 Major
PRIOR EMPLOYMENT

Start with most recent.
Employer #1
Employer *
Phone Number *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Position *
Job Responsibilities *
Dates Employed: From *

Month Day Year
To: *

Month Day Year
Immediate Supervisor *
Reason For Leaving *
Final Salary/Wage *
Employer #2
Employer *
Phone Number *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Position *
Job Responsibilities *
Dates Employed: From *

Month Day Year
To: *

Month Day Year
Immediate Supervisor *
Reason For Leaving *
Final Salary/Wage *
Employer #3
Employer *
Phone Number *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Position *
Job Responsibilities *
Dates Employed: From *

Month Day Year
To: *

Month Day Year
Immediate Supervisor *
Reason For Leaving *
Final Salary/Wage *
We may contact the employers listed above unless you indicate those you do not want us to contact below.
Employer not to Contact
Reason not to Contact
Have you been employed by Arrowhead West, Inc. in the past? *

Yes No
If yes, please list location, approximate dates of employment, and name used at the time:
Are you able to perform the job functions of the position(s) for which you are applying with or without a reasonable accommodation? *

Yes No
References

Please list 3 references other than relatives or previous employers.
Reference #1
Full Name *

First Name Last Name
Phone Number *
Years known *
Reference #2
Full Name *

First Name Last Name
Phone Number *
Years known *
Reference #3
Full Name *

First Name Last Name
Phone Number *
Years known *
Please state why you feel you are qualified for this position: *
Have you ever been convicted of a crime? *

Yes No
If yes, was it a felony or misdemeanor, please explain:
Dates of conviction(s):
Referral
How did you become aware of employment opportunity at Arrowhead West Inc.? *

Newspaper Presentation Walk-In AWI Staff (Please list name(s) below)
List AWI Staff Name here:
ARROWHEAD WEST, INC.

AFFIRMATION OF

DRUG- AND ALCOHOL-FREE TESTING POLICY

FOR ON-LINE APPLICANTS

STATEMENT OF POLICY

Arrowhead West, Inc. is committed to ensure a safe and drug and alcohol-free workplace for all company employees and the general public. As a public employer, the company has a compelling interest in establishing reasonable condition of employment. Prohibiting employee drug and alcohol use is one such condition.

Arrowhead West, Inc. is concerned with the well-being of its employees and the need to maintain employee productivity. The intent of the Arrowhead West, Inc.’s Drug- and Alcohol-Free Testing Program is to offer a helping hand to those who need it, while sending a clear message that any illegal drug or alcohol use is contradictory with public services and WILL NOT BE TOLERATED!

It is the policy of Arrowhead West, Inc. that all applicants who receive a conditional offer of employment submit to a drug and alcohol test to document they are drug and alcohol free. Refusal to comply with this requirement will be considered the equivalent of receiving a confirmed "positive" results for employment and disqualification purposes. Any applicant who receives a confirmed "positive" drug screen result will have the offer of employment withdrawn and will be subject to disqualification from other application for company employment for a period of two years from the effective date of the disqualification action.

I hereby authorize the disclosure of the test results to Arrowhead West, Inc. subsequent to the required review by the medical review officer.

AFFIRMATION OF POLICY

As an applicant for a position, I affirm that I have read and understand the Arrowhead West, Inc.’s Anti-Drug and Alcohol Misuse Prevention Policy and Procedures noted above, and I am aware that any offer of employment is conditional upon my taking a drug and alcohol test and the results thereof. If hired into a position for Arrowhead West, Inc., I agree to abide by all provisions of the anti-drug policy as a condition of my continued employment with the company.
Summary of Hiring Practices
A conviction record will not necessarily be a bar to employment, and factors such as age and time of offense, the seriousness and nature of the violation, and the applicant’s rehabilitation will be considered in the hiring decision.

I understand that the U.S. government requires the company to verify my eligibility for U.S. employment and my identity. I understand that the company must decline to hire me if I fail to present adequate proof of my eligibility and identity.

Driving is a responsibility of all positions at Arrowhead West, Inc., therefore, your motor vehicle record will be checked through the State where your license is issued. To conduct this check, we need the following information regarding your driver's license:
State of Issuance *
Driver's License Number *
Please include dashes.
We will request clearance through KDADS Health Occupations Credentialing(HOC), Kansas Nurse Aid Registry for Abuse, Neglect or Exploitation, Child/Adult Central Registry, IntelliCorp Nationwide Registry and Office of Inspector General (OIG) as part of our reference checking process. Employment is contingent on appropriate reference checks.

I hereby certify that I have read the Affirmative Action Plan of Arrowhead West, Inc. and had an opportunity to discuss or ask questions about the plan.

The information provided by me in the Application for Employment is true and complete to the best of my knowledge. I understand that if I am employed, misrepresentation or any false statements may be considered cause for possible dismissal. I hereby authorize you to investigate all statements in this application as may be necessary.
Acknowledgement *

By checking this box I acknowledge that I have read and understand the Summary of Hiring Practices and Arrowhead West, Inc.’s Drug and Alcohol-free Testing Policy.
Date *

Month Day Year
Should be Empty:

ARROWHEAD WEST, INC.

EDUCATION

PRIOR EMPLOYMENT

Employer #1

Employer #2

Employer #3

References

Reference #1

Reference #2

Reference #3

Referral

Summary of Hiring Practices