ComWell Careers

Application For Employment

Date Available to Work

Referral Source
—Please choose an option—AdvertisementFriend/RelativeWalk-InOther

Position(s) you're applying for

Name

Address

Email Address

Phone Number

Have you been convicted of a Felony?
—Please choose an option—YesNo

If Yes, Please Explain

*An applicant is not obligated to disclose sealed or expunged records of conviction or arrest.

ComWell is an Equal Opportunity Employer. To assist in completion of Affirmative Action Goals, we invite you to complete the following information. Completion of this information is not required.

Gender
—Please choose an option—MaleFemale

Ethnicity
—Please choose an option—Caucasian/White, not HispanicBlack, not HispanicAmerican Indian or Alaskan NativeAsian or Pacific IslanderHispanic

Do you have a valid Illinois Driver’s License?
—Please choose an option—YesNo

Have you ever been employed as a professional driver?
—Please choose an option—YesNo

If yes, which type?
—Please choose an option—Car/VanBusTruck

Has your Driver’s License ever been suspended or revoked?
—Please choose an option—YesNo

Education

High School

Graduated?
—Please choose an option—YesNoGED

Higher Education

Graduated?
—Please choose an option—YesNo

Dates Enrolled From/To

Major

Describe Specialized Training or Skills Relevant to position(s) applying for

Employment History

Employer

Start Date

End Date

Job Title

Supervisor

Phone Number

Duties and Responsibilities

Reason for Leaving

Employer

Start Date

End Date

Job Title

Supervisor

Phone Number

Duties and Responsibilities

Reason for Leaving

Employer

Start Date

End Date

Job Title

Supervisor

Phone Number

Duties and Responsibilities

Reason for Leaving

Employer

Start Date

End Date

Job Title

Supervisor

Phone Number

Duties and Responsibilities

Reason for Leaving

Provide three references, not related to you or who are not Previous or Current Employees of ComWell.

Personal Reference #1 Name

Personal Reference #1 Email Address

Personal Reference #1 Phone Number

Personal Reference #2 Name

Personal Reference #2 Email Address

Personal Reference #2 Phone Number

Personal Reference #3 Name

Personal Reference #3 Email Address

Personal Reference #3 Phone Number

Professional Staff Addendum

Have you ever had any licensing board or professional ethics body ever require you to surrender your license or found you guilty of violation of ethics codes, professional misconduct, professional conduct, incompetence or negligence in any state or country?—Please choose an option—YesNo

If yes, please give full particulars in order for your application to be considered.

Are there any complaints, charges or investigations pending against you by any licensing board for professional ethical codes, professional misconduct, unprofessional conduct, incompetence or negligence in any state or country? —Please choose an option—YesNo

If yes, please give full particulars and copies of charges, correspondence and any findings in order for your application to be considered

Are there any circumstances of which you are aware of that may result in any professional liability claim or suit being made against you, your predecessors in business or against any past or present partner(s)? —Please choose an option—YesNo

If yes, please give full particulars in order for your application to be considered

Have you engaged in or ever been engaged in any sexual misconduct with any of your current or former patients or any current or former patient's spouse or any person with a direct relationship to the patient or former patient (for example a guardian, blood relative of the patient or spouse or any person sharing the patient's domicile)? —Please choose an option—YesNo

(Sexual misconduct means any actual or alleged erotic physical contact or attempt threat or proposal thereof.) If yes, please give full particulars in order for your application to be considered.

Additional Comments

I understand that this application is not intended to be a contract of employment. I also understand that, if employed, false or misleading information given on my application or interview may result in my discharge.

I understand this application will be active for a period of one year; after that time, if I wish to be considered for employment, I must submit a new application.

I understand that ComWell will thoroughly investigate my work and personal history and verify all data given on this application, on related papers, and in interviews. I authorize all individuals, schools and firms named therein, except my current employer if so noted, to provide any information requested about me, and I release them from all liability for damage in providing any information.

I certify that all the statements herein are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal of employment.

*If you have a resume and cover letter, please attach your document below and submit to our Human Resource Department:

*File size limit for upload is 3MB.
*Acceptable file types are .PDF, .DOC, .DOCX, .JPG, .JPEG & .PNG.