3303 S Meridian
Oklahoma City, OK 73119
Fax 405.682.3433

We consider applicants for all positions without regard to race, color, religion, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

Positions Applying for:    
Date of Application:    
How did you
learn about us?
Last Name:    
First Name:    
Middle Name:    
Maiden Name:    
Home Phone #:    
Alternate Phone #:    
Social Security #:    
Can you provide required proof of eligibility to work?    

Have you ever filed an application with us before?    

If yes, please indicate the date.   
Have you ever been employed by us before?    

Are you currently employed?    

May we contact your current employer?    

What date are you available to begin work?   
Are you available to work:
 Full Time     Part Time     Temporary
Have you ever been excluded, suspended, debarred or otherwise determined to be ineligible to participate in any federal health care program?

Have you ever been convicted of or given a deferred or suspended sentence for a criminal misdemeanor or felony? (Conviction, deferred or suspended sentence will not necessarily disqualify an applicant from employment.)

If yes, please explain


Do not put "See Resume". If you require more space, please attach a separate sheet of paper.
School Type        Name /
Address of School
       Course of Study        Years
High School:                            
Professional Training:
Other (Please specify):                            


Do not put "See Resume". If you require more space, please attach a separate sheet of paper.
(Please indicate software in which you are proficient.)
    Level of Proficiency

(Please indicate any languages you speak, read and/or write.)
    Level of Proficiency

(Please indicate any other specialized skills.)
    Level of Proficiency

Employment Experience

Do not put "See Resume". Start with your present or most recent employer. Include any job-related military or voluntary assignments and activities. You may exclude organizations which indicate color, religion, gender, national origin, disabilities or other protected status.
Telephone #:    
Reason for leaving:    
Dates of Employment:
From:      To: 
Job Title:  
Job Duties:  
Rate of Pay  

Do you have another employer to add?

Professional, Trade, Business or Civic Activities

Academic and Professional References

NameAddressPhone NumberRelationship
This application for employment shall be considered active for a period of time not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at this time.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the employee may resign at any time and the employer may discharge the employee at any time with, or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.
I understand that a background investigation will be conducted and may include reference checks from past employers, criminal background checks, worker's compensation, exclusions from participating in federal healthcare programs and, for applicable positions, driving record and financial history.
 I agree to the terms of the background investigation as stated above.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all the rules and regulations of the employer.
 I certify that answers given on this application are true and complete to the best of my knowledge.