Employment Application Employment ApplicationPosition Desired* Name* First Middle Last Address* Street Address City, State ZIP / Postal Code Phone*Email* Date of Birth* MM slash DD slash YYYY Social Security #* Drivers License #* Are you known to employers/references/schools by another name? Why do you want to join New Birth Company?*Highest Level of Education Attained (List Institution + Degree)* Licenses/Registrations License #: State: If appropriate, please attach a copy of midwifery / nursing license and certification documentsMax. file size: 50 MB.Has your license ever been suspended or revoked? Yes No If yes, please list WHEN and WHERE your license was suspended or revoked: Work Experience: List your last two employers or last two positions, starting with the most recent:Employer 1: Employer Job Title Supervisor's Name Supervisor's Phone # Ending Pay Please describe your job duties Employer 2: Employer Job Title Supervisor's Name Supervisor's Phone # Ending Pay Please describe your job duties Other Related Experience:Please describe here any other related professional certifications, honors, special skills, qualifications, or experience not mentioned elsewhere.Please attach a copy of your resume:FileMax. file size: 50 MB.Have you ever been convicted of a felony?Please note: A conviction record will not necessarily bar an applicant from employment. Individual circumstances will be considered relative to the job requirements. Yes No AFFIRMATION: PLEASE SIGN BELOW*I affirm that I am legally able to work in the United States and that the facts set forth above in my application for employment are true, correct, and complete to the best of my knowledge. I understand that I may be required to submit information not requested on this application form; that New Birth Company may verify any information provided by me in the employment process; and that incomplete information or omission of my signature is just cause for rejection of my application. I understand and agree that this is only an application and not an offer of employment. CAPTCHA
