Careers Form

* = Required Information

1. Employer Information

Employer:Gateway Healthcare Services LLC
3022 Javier Road, Suite #207
Fairfax, VA 22031
Phone: 703-462-8725

It is the policy of Gateway Healthcare Services LLC to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.

2. Applicant Information

Applicant Full Name *

Home Address *

City *

State

Zip Code *

Number of Years At This Address

Daytime Phone

Evening Phone

Mobile Phone

Social Security Number

Driver's License (State/Number)

3. Emergency Contact

Who should be contacted if you are involved in an emergency?

Contact Name

Relationship To You

Address

City

State

Zip Code

Daytime Phone

Evening Phone

4. Job Position Applied For

5. Who referred you to our company?

Do you have any friends or relatives who work here?

Yes

List of friends or relatives who work here

6. Have you applied to our company previously?

Yes

When?

7. Are you at least 18 years old?

Yes

8. How will you get to work?

9. If applicable, are you available to work overtime?

Yes

10. If you are offered employment, when would you be available to begin work?

11. If hired, are you able to submit proof that you are legally eligible for employment in the United States?

Yes

12. Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation?

Yes

What reasonable accommodation, if any, would you request?

13. Applicant's Skills

List any skills that may be useful for the job you are seeking. Enter the number of years of experience, and circle the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)

Skill

Years of Experience

Skill

Years of Experience

14. Applicant Employment History

List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment. If additional space is needed, continue on the back page of this application.

Employer Name

Supervisor Name

Address

City

State

Zip

Job Duties

Dates of Employment (Month/Year)

Reason for Leaving

Employer Name

Supervisor Name

Address

City

State

Zip

Job Duties

Dates of Employment (Month/Year)

Reason for Leaving

Employer Name

Supervisor Name

Address

City

State

Zip

Job Duties

Dates of Employment (Month/Year)

Reason for Leaving

Employer Name

Supervisor Name

Address

City

State

Zip

Job Duties

Dates of Employment (Month/Year)

Reason for Leaving

15. Applicant's Education and Training

College / University Name

College / University Address

Did you receive a degree?

Yes

Please indicate the degree(s) you received

High School / GED Name

High School / GED Address

Did you receive a degree?

Yes

Please indicate the degree(s) you received

Other Training (graduate, technical, vocational)

Please indicate any current professional licenses or certifications that you hold

16. References

List any two non-relatives who would be willing to provide a reference for you.

Name

Address

City

State

Zip

Telephone

Relationship

Name

Address

City

State

Zip

Telephone

Relationship

Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize Gateway Healthcare Services LLC to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

Applicant Name *

Date