(855) 219-1563

Application for Employment

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APPLICANT NOTE: This form is intended for use in evaluating your qualifications for employment. It is not an employment contract. Please answer all questions completely and to the best of your ability. False or misleading statements are grounds for refusal or termination of employment benefits. It is the policy of this company as an Equal Opportunity Employer to ensure that there shall be no discrimination against any employee or applicant for employment on the basis of age, race, color, creed, marital status, religion, sex, national origin, disability or veteran status, or any other status protected by law.

* Denotes Required Field

Personal Data * Specify legal name as registered with social security

Personal Information


Are you currently subject to a covenant not to compete, non-solicitation agreement, confidentiality agreement, or any other type of agreement with a current or former employer that might affect your employment with JH or a JH company? *

If yes, please explain and provide a copy of the agreement. (Limit 255 characters)

Have you previously applied for a position with Jackson Healthcare or affiliates? *

If yes, please indicate the date(mm/yy) and the position applied for.

Have you ever been employed by JH or a JH company? *

If yes, please indicate the starting and ending dates.


List any other names, AKAs or maiden names that have been used past or present or any other names by which you received your high school diploma or other degrees. Also provide the approximate year this alternate name was last used, if available.


Please list all other places in which you lived during the last 7 years.

Have you ever been convicted of or plead guilty to a crime? *

A conviction or guilty plea will not necessarily bar you from employment at JH.

In California, "crime" excludes any conviction more than 2 years old for a marijuana-related offense.

In Illinois, applicants are not required to disclose sealed or expunged records of conviction or arrest.

Massachusetts Applicants: An applicant for employment with a sealed record on file with the commissioner of probation may answer "No" with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, any applicant for employment may answer "no record" with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution.

If yes, please explain. (Limit 255 characters)


Employment Desired


Employment History

Please provide details of your employment history, starting with the most recent first. You must complete at least 1 employer block on this page.  Commission, bonus, incentive and any other forms of additional compensation should be noted in the Other Compensation/Bonus field.

May we contact your current employer? *

Employer 1

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Military Service

Complete if you have ever served in the US Military. Do not include current National Guard or Military reserve status.


Please provide details of your education.

High School

College / University 1 show/hide
College / University 2 show/hide
College / University 3 show/hide
W-II HIRE Act Required Information *

Voluntary Information

The following information is being requested in accordance with EEOC federal regulations. The information is voluntary and will not be used when considering you for employment with our company.

Racial or Ethnic Group


Military Service

By signing and submitting this application, I understand and agree to the following:

Neither this document nor any other company procedures and communications are intended to be interpreted as a promise or guarantee of future or continued employment or as stating provisions and terms of employment. JH and JH employees recognize their mutual right to end their employment relationship at any time and acknowledge that such a relationship is one of employment at will. Except with respect to employment at will, JH and JH companies reserve the right to change or make exception to its Human Resources policies, documents, procedures and benefits, including those for retirees, at any time without notice. No representative of JH has any authority to make an agreement to the contrary.

It is JH's policy to verify pertinent educational and employment information and, where required, personal data contained in this application. Accordingly, I hereby authorize JH or those acting on its behalf to investigate any or all statements contained in this application. I certify that the above statements are true and correct to the best of my knowledge and that any misstatement may result in termination from JH at any time. To enable JH to fulfill its responsibilities under the Immigration and Control Act of 1986, employment is subject to providing proof of identity and authorization to work in the United States satisfactory to JH.

I herby certify that all the statements and answers set forth on the application, background questionnaire, and/or my resume are true and complete to the best of my knowledge, and I understand that if any such statements and/or answers are found false or that information has been omitted, such false statements or omissions will be just cause for the termination of my employment. Further, I understand that by requesting this information, no promise of employment is being made. I am willing that a photocopy of this authorization be accepted with the same authority as the original; and that if employed by the above-named company (except if employed in the state of California), this authorization will remain in effect throughout such employment.

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