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Step 1 of 6 – Personal Information

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Personal Information
Todays Date*

Date Format: MM slash DD slash YYYY
Name*

First

Middle

Last
Address*

Street Address

City

State

ZIP Code
Phone Number*
Email

Enter Email

Confirm Email
Social Security Number*

Employment Eligibility
Are you 18 years or older?*
- Yes
- No
Are you a United States Citizen?*
- Yes
- No
Are you legally authorized to work in the U.S.?*
- Yes
- No
If no, are you an alien authorized to work in the U.S.?
- Yes
- No
Availability
Desired Position
Wages Desired
Available Start Date*

Date Format: MM slash DD slash YYYY
Type of Employment Desired?
- Full-Time
- Part-Time
- PRN
Are you willing to work?
- Select All
- Days
- Evenings
- Weekends
- Holidays
- Overtime
Were you ever employed here?
- Yes
- No
If yes, when?

Date Format: MM slash DD slash YYYY
Do you know anyone employed here?
- Yes
- No
If yes, who?
Can you travel if your job requires it?
- Yes
- No
Do you have a valid diver’s license?
- Yes
- No
Do you have reliable transportation?
- Yes
- No
Please list the days and times you are available to work
Monday

From (time) To (time)
Tuesday

From (time) To (time)
Wednesday

From (time) To (time)
Thursday

From (time) To (time)
Friday

From (time) To (time)
Saturday

From (time) To (time)
Sunday

From (time) To (time)

Education
High School Name & Location*
Graduated?*
- Yes
- No
GPA
College/University Name & Location
Graduated?
- Yes
- No
GPA
Trade School
Graduated?
- Yes
- No
GPA

Professional References
Give the names of three persons you have worked with; paid or unpaid, for at least (1) year.
Name
Phone
Yeas Aquainted
Name
Phone
Yeas Aquainted
Name
Phone
Yeas Aquainted

Work Experience
In the following 3 boxes please list your work experience.
- Dates from – to:
- Employer Name:
- Employer Phone:
- Employer Address:
- Job Title:
- Supervisor:
- Reason for leaving:
- Pay rate:
Employer #1 or Current Employer
Employer #2
Employer #3
May we contact your current employer?
- Yes
- No
Are there any limitations prohibiting you from performing this job?
- Yes
- No
If yes, Please Explain:

Signature & Resume
I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I UNDERSTAND THAT MISREPRESENTATION OR OMISSION OF FACTS CALLED FOR IS CAUSE FOR DISMISSAL. FURTHER, I UNDERSTAND AND AGREE THAT MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND I MAY, AT THE DISCRETION OF THE EMPLOYER, BE TERMINATED AT ANY TIME WITHOUT ANY PREVIOUS NOTICE.
Signature:*
Resume

If you’d like to submit your resume with your application please upload it here.

Locations
New Mexico Branches
- 408 N. Auburn Ave.
  Farmington, NM 87401
  (505) 326-6024
- 6382 A Highway 550
  Cuba, NM 87013
  (575) 289-2726
- Tse Bit Ai Shopping Center
  Highway 491, Suites 8 & 9
  Shiprock, NM 87420
  (505) 368-3897
Arizona Branch
- 580 E. Old Linden Road, Suite 8
  Show Low, AZ 85901
  (928) 537-7601

Employment Opportunities

Are you seeking employment in the health service industry? We have opportunities within both of our companies.

To apply, click on the Employment Application link below and print it out. When you have completed the form, please fax it to our Farmington location at (505) 327-6923 to the attention of our HR Director.
Download Employment Application
Online Application

Give us a call

Farmington, NM: (505) 326-6024
Cuba, NM: (575) 289-2726
Shiprock, NM: (505) 368-3897
Show Low, AZ: (928) 537-7601
Email Us

January 2020

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© Copyright Southwestern Companies. All Rights Reserved

Need A Ride?

Give us a call

Farmington, NM: (505) 326-6024
Cuba, NM: (575) 289-2726
Shiprock, NM: (505) 368-3897
Show Low, AZ: (928) 537-7601

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