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EMPLOYMENT APPLICATION

APPLICANT INFORMATION

First Name

Middle Name

Last Name

Date of Birth

Phone Number

Email

Driver License Number

Licensures/Credentials

Oklahoma License Number

Street Address

AVAILABILITY

Position Applying For

Desired Employment Status

Full-Time

Part-Time

PRN

Contract

Desired Location

Clinic

Long-Term Care Facilities

Schools

Telehealth

Any Location Needed

Are you available to see patients in-person & via telehalth?

Yes

No

If hired, what day could you start?

GENERAL INFORMATION

Have you previously worked for Pinnacle Care?

Yes

No

Do you have friends or relatives who work for Pinnacle Care?

Yes

No

Are you able to perform essential functions for job you are applying for (with or without reasonable accommodations)?

Yes

No

Have you ever been convicted of any criminal offense (not minor traffic violations)?

Yes

No

Are you at least 18 years of age?

Yes

No

Are you authorized to work in the US?

Yes

No

If you selected "No", please explain

If you selected "Yes", please explain

BACKGROUND & EDUCATION

Select the highest level of education you have completed.

Have you ever been in the military?

Yes

No

Special Training/ Credentialing

WORK HISTORY

Most Recent Employer

Name of Employer

Address

Phone Number

Start Date - End Date

Job Title and Responsibilities

Reason For Leaving

Previous Employer

Name of Employer

Address

Phone Number

Start Date - End Date

Job Title and Responsibilities

Reason For Leaving

REFERENCES

Name

Phone Number

Relationship

Reference 1

Reference 2

Name

Phone Number

Relationship

I certify that all answers given by me in this application are true, accurate, and complete. I understand that the falsification, misrepresentation or omission of fact on this application (or any other accompanying documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how it was discovered.

Upload Resume (Optional)

Upload supported file (Max 15MB)

*The information collected on this application may be used to perform a background check.

*Pinnacle Care is an equal opportunity employer and does not discriminate on the basis of race, creed, gender, disability, age, and/or any other basis.

THANK YOU FOR SUBMITTING YOUR APPLICATION.

Someone from our team will be in touch with you soon.

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Address: 2701 W University Blvd, Durant, OK 74701

Phone: 580-740-4053 | Fax: 877-725-8976

Check out our sister company, CompleteOK, for all of your healthcare needs at home

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