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347 East Stevens Street
Cookeville, TN
PHONE: (931) 528-5514

It is the policy of CHC that all employees must pass a physical examination including a drug test as a condition of employment. CHC will only withdraw a condition offer of employment based upon the results of a physical examination if the criteria that the individual failed to satisfy are job related and consistent with business necessity and the individual would not be able to perform the job for which he or she was hired without reasonable accommodation. All expenses for the test will be borne by the company provided you remain in employment of CHC for 90 days. Otherwise, you will be expected to reimburse the company for the expense on a pro rata basis.

Please be sure you are comfortable with this policy before pursuing employment with CHC.



Application for Employment

We consider applications for all positions without regard to race, color, religion, creed, sex, national origin, disability, sexual orientation, citizenship status, or any other legally protected status.

Position(s) applied for
 Date of Application
  Advertisement
  Employment Agency 		  Relative
  Friend 		  Inquiry
  Other  
Last Name
 First Name
 Middle Name
Street Address
 Number
 City
 State
 Zip Code
Telephone Number(s)
 Social Security Number (Voluntary)
Best time to contact you at home is: :
If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes    No
Have you ever filed an application with us before? Yes    No
If Yes, give date
Have you ever been employed with us before? Yes    No
If Yes, give date
Do any of your friends or relatives, other than spouse, work here? Yes    No
Are you currently employed? Yes    No
May we contact your present employer? 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
Date available for work / / What is your desired salary range?
Are you available to work: Full Time    1st Shift    2nd Shift      3rd Shift
Part Time   Mornings  Afternoons  Evenings
Temporary  (Dates Available:   // - / /)
Are you currently on “lay-off” status and subject to recall? Yes    No
Can you travel if job requires it? Yes    No

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

EDUCATION

  Name and Address Of SchoolCourse of StudyNumber of Years CompletedDiploma / Degree
Elementary School
High School
Undergraduate College
Graduate
Professional
Other:

Describe any specialized training, apprenticeship, skills, and extra-curricular activities:

Describe any job-related training received in the United States military:


EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations that indicate race, color, religion, gender, national origin, disabilities, or other protected status.

1.
Employer


Address


 Dates Employed
From:
     To: 		WORK PERFORMED
Telephone Number(s)


Job Title
Supervisor

Reason for Leaving


 Hourly Rate/Salary
Start:
Final:
2.
Employer


Address


 Dates Employed
From:
     To: 		WORK PERFORMED
Telephone Number(s)


Job Title
Supervisor

Reason for Leaving


 Hourly Rate/Salary
Start:
Final:
3.
Employer


Address


 Dates Employed
From:
     To: 		WORK PERFORMED
Telephone Number(s)


Job Title
Supervisor

Reason for Leaving


 Hourly Rate/Salary
Start:
Final:
4.
Employer


Address


 Dates Employed
From:
     To: 		WORK PERFORMED
Telephone Number(s)


Job Title
Supervisor

Reason for Leaving


 Hourly Rate/Salary
Start:
Final:
List professional, trade, business or civil activities and offices held.
You may exclude membership that would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:


ADDITIONAL INFORMATION

Other Qualifications
Summarized special job-related skills and qualifications acquired from employment or other experience.



SPECIALIZED SKILLS (CHECK SKILLS/EQUIPMENT OPERATED)

  Terminal

  PC/MAC

  Typewriter

WPM
  Spreadsheet

  Word Processing

  Shorthand

WPM
Production/Mobile Machinery (List All)
Other (List All)

State any additional information you feel may be helpful to us in considering your application.

Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Can you perform the essential functions of the job, for which you are applying, either with or without a reasonable accomodation?
YES    NO

REFERENCES

1.
     Name:
Phone #:
Address:
2.
     Name:
Phone #:
Address:
3.
     Name:
Phone #:
Address:

I warrant that this info is true and represents my experience accurately.
I understand that a personal signature will be required at interview.