Pre-Employment form for The Health Care Management Group

Employment at HCMG

Please complete the Online Pre-Employment form below and submit. We will review and contact you as soon as possible!

Online Pre-Employment Application

PERSONAL INFORMATION

Name
	(Last)	(Middle)	(First)

Address
Street
City		State
Zip Code
Telephone		E-Mail


Position(s) applying for:		Rate of Pay desired:
Available to work: Full-Time Part Time
Shift Preference: 1st 2nd 3rd Rotating
Will you work different shifts? Yes No
Are you currently employed? Yes No
Date available to start work?
Check the facilities you are interested in working at:
Health Care Management Group
Alois Alzheimer Center
Brookwood Retirement Community
Clovernook Health Care Pavilion
Florence Park Care Center
Loveland Health Care Center

PROFESSIONAL LICENSE AND/OR CERTIFICATIONS

Are you currently:	Accredited	Certified	Licensed
	Registered	have an Interim Permit

License/Certification	State of Issuance	Licensing Agency	Expiration Date	Number

If issuing state is not Ohio, have you applied for reciprocity? Yes No

Has your professional license ever been revoked, suspended, or subject to any disciplinary action?
Yes No

If yes, list where, for what, and give dates:

EDUCATIONAL BACKGROUND

Type of School	Name	Course of Study	Did you graduate?	List Degree or Diploma

High School
College
Business or Trade
Other

PREVIOUS WORK EXPERIENCE
(List last four positions held – list most recent first)

Name of Employer:
Address:
City:
State:
Zip:
Telephone No.:
Job Duties:
Reason for Leaving:

Dates of Employment:

From to

Ending Salary:

Supervisor’s Name:

Name Worked Under:

Name of Employer:
Address:
City:
State:
Zip:
Telephone No.:
Job Duties:
Reason for Leaving:

Dates of Employment:

From to

Ending Salary:

Supervisor’s Name:

Name Worked Under:

Submit your pre-employment application!
This Pre-Employment Application is an initial screening of
candidates interested in our employment opportunities.
If you appear to have the skills and experience needed for
our current vacancies we will be contacting you.