* = Required Information

It is this facility's policy to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, or disability.
Present Address
* Phone : Social Security Number : Are you at least 18 years old?  YesNo
* Position Applying For :
Full Time Part Time Per Visit
Part Time Pool
Shift
Day Night
Evening W / E
* Salaries Requirements :
* Date Available :
If you are not a US Citizen, have you the legal right to remain permanently in the US?  YesNo
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?  YesNo
Have you been convicted of a crime (excluding misdemeanors and traffic offenses) and/or released from confinement following a conviction for any criminal offense within the past 7 years?  
YesNo
  If yes, give date, place and nature of each such conviction.
Date : Place : Nature :
Are you presently charged with any violation of the law other than traffic violation?  
YesNo
  If yes, give date, place and nature of each such conviction.
Date : Place : Nature :

Educational History
Type of School Name & Location of School Last Year Attended Graduated Degree
High School 9101112
College 9101112
College 9101112
Other From  To 
List professional licenses you possess. Indicate type of license, number, and state  
List any memberships in professional organizations, honors or activities which you feel would enhance your application, excluding those that would indicate race, color, religion, sex, national origin, or disability.   
List languages spoken other than English :  
List other skills applicable to the position for which you are applying, including computer experience, typing speed and etc.   
In case of an emergency, notify:   

Work History
  Company Name
  Complete Address incl City/
State/Zip 
  Phone Number
  Supervisor's Name
  Date Started
  Date End
  Type of Business 
Full Time
Part Time
Per Visit
  Salary 

  Reason For Leaving :
  OK to contact
  Supervisor
  YesNo
Describe your job title, responsibilities and accomplishments  
  Company Name
  Complete Address incl City/
State/Zip 
  Phone Number
  Supervisor's Name
  Date Started
  Date End
  Type of Business 
Full Time
Part Time
Per Visit
  Salary 

  Reason For Leaving :
  OK to contact
  Supervisor
  YesNo
Describe your job title, responsibilities and accomplishments  
  Company Name
  Complete Address incl City/
State/Zip 
  Phone Number
  Supervisor's Name
  Date Started
  Date End
  Type of Business 
Full Time
Part Time
Per Visit
  Salary 

  Reason For Leaving :
  OK to contact
  Supervisor
  YesNo
Describe your job title, responsibilities and accomplishments  

Personal References
Name Phone Relationship  
 
 
 
 
 


In making application for employment :
  • I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

  • I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

  • I understand and agree that if I am offered employment by the facility, my employment will be for no definite term and that either I, or the facility will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the facility.

  • I understand, if I am an unlicensed person who has direct patient contact, that the agency will perform a criminal history check per State Regulations.

* Release: I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.