Please select checkboxes that match your skills and preferences.
Please check all that apply, and enter the expiration date and any notes as applicable.
Please provide all employment information for your past three employers starting with the most recent.
I hereby authorize ICHS to contact, obtain, and verify the accuracy of information contained in this
application from all previous employers, educational institutions, and references. I also hereby release
from liability the potential employer and its representatives for seeking, gathering, and using such
information to make employment decisions and all other persons or organizations for providing such
I understand that this is a drug free work place and that I will be required to take a drug test.
I understand that any misrepresentation or material omission made by me on this application will be
sufficient cause for cancellation of this application or immediate termination of employment if I am
employed, whenever it may be discovered.
I authorize the potential employer to perform a background check of my credit history, criminal history,
and driving history. I also hereby release from liability the potential employer and its representatives
for seeking, gathering, and using such information to make employment decisions and all other
persons or organizations for providing such information.
If I am employed, I acknowledge that there is no specified length of employment and that this
application does not constitute an agreement or contract for employment. Accordingly, either I, or the
employer can terminate the relationship at will, with or without cause, at any time, so long as there is
no violation of applicable federal or state law.
I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate
against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the ADA. I also understand that if I am employed, I will be required to
provide satisfactory proof of identity and legal work authorization within three days of being hired.
Failure to submit such proof within the required time may result in immediate termination of
I represent and warrant that I have received and fully understand the foregoing, and that I seek
employment under these conditions.
As the applicant, I hereby authorize ICHS to request and receive from all prior employers within one
year of the date of this application, any and all pertinent information concerning my prior employment
and its termination, including reasons for such termination.
I certify that answers given are true. I authorize investigation of my statements and a criminal
background check to be completed. False or misleading information may result in my discharge. I
understand I am required to abide by the rules and regulations of the agency.
I also understand that the agency is an Equal Opportunity Employer, and all applicants are considered
for all positions without regard to race, color, religion, sex, national origin, age or marital status.