Shreveport Positions
*Required fields have asterisk

1) Personal Information
*Last name: *First name:
Middle name: Maiden name or alias
Phone: (xxx-xxx-xxxx) *Email
*Social Security Number:

2) Current address
*Number and street: *City: *State: *Zip:
Country:

3) General Information
*Are you legally authorized to work in the United States?
*Have you ever been convicted of a crime other than a minor traffic violation?
 If yes, offense charged:
 If yes, date(s) of the offense:
 If yes, punishment or outcome:
 If yes, explain:
*Are you currently under investigation or have you ever been sanctioned?
 If yes, provide reason(s) for sanction and outcome(s):
 If yes, provide date(s) for sanction:

4) Job sought
*Desired Department:
*Desired Title:
Second Desired Department:
Second Desired Title:
Third Desired Department:
Third Desired Title:
Desired salary:
Job type:
Availability:
Can you work on weekends:
*Date available to start:

5) Education

High School

*Name and location of school:
*Last year completed:
*Diploma received?
Registration # or degree: (example: High School Diploma)

College

Name and location of school:
Last year completed:
Diploma received?
Registration # or degree: (example: B.A.)

Graduate School

Name and location of school:
Last year completed:
Diploma received?
Registration # or degree: (example: PhD)

Trade School

Name and location of school:
Last year completed:
Diploma received?
Registration # or degree:

6) Current Professional Licenses
License or Certification Type:
Other License Type (not in list):
License or Certification Number:
License or Certification Expiration Date:

7) Work History

Employer Information - Most Recent or Current

*Name of employer:
Employer number and street:
City: State: Zip:
Country:
Job title: Hours worked per week:
Starting date (e.g. 02/11): Final date of employment:
*Current or final wage: Name of last supervisor:
Phone (xxx-xxx-xxxx):
Reason for leaving:
*Job duties and responsibilities:
(If still employed, leave reason blank)

Employer Information - Second Most Recent

Name of employer:
Employer number and street:
City: State: Zip:
Country:
Job title: Hours worked per week:
Starting date (e.g. 02/11): Final date of employment:
Current or final wage: Name of last supervisor:
Phone (xxx-xxx-xxxx):
Reason for leaving:
*Job duties and responsibilities:

Employer Information - Third Most Recent

Name of employer:
Employer number and street:
City: State: Zip:
Country:
Job title: Hours worked per week:
Starting date (e.g. 02/11): Final date of employment:
Current or final wage: Name of last supervisor:
Phone (xxx-xxx-xxxx):
Reason for leaving:
*Job duties and responsibilities:

Employer Information - Fourth Most Recent

Name of employer:
Employer number and street:
City: State: Zip:
Country:
Job title: Hours worked per week:
Starting date (e.g. 02/11): Final date of employment:
Current or final wage: Name of last supervisor:
Phone (xxx-xxx-xxxx):
Reason for leaving:
*Job duties and responsibilities:

8) *Attach Resume

Attaching a resume will help us to better evaluate your skills and abilities and is strongly encouraged.

9) Legal Disclaimer

10) Referral
*Referral Type:

11) Misc.

12) EEO

University Health requests the data below so we may comply with federal Equal Employment Opportunity law requirements. The information is strictly voluntary and in no way influences employment prospects

*Gender:
*Race and Ethnicity: