Careers Form

Applicant Information

Date

Full Name

Last *

First *

M.I

Address

Street Address

Apartment Unit #

City

State

Zip Code

Contact # *

Email Address *

Date Available

Social Security No.

Desired Salary $

Position Applied for

Do you have experience?

Yes

No

Indicate referral source below

Friend	Relative
Walk In	Employment Agency
Advertisement	Other

Time Frame of Employment

Are you currently employed?

Yes

No

May we contact your present employer?

Yes

No

Are you a citizen of the United states?

Yes

No

If no, are you authorized to work in U.S?

Yes

No

Have you ever worked for this company?
Yes No

If yes, when?

Are you available to work:

Every Weekend

Holidays

Desired shift

Days

Evenings

Night

How far are you willing to commute to work?

Have you ever been convicted of a misdemeanor or a felony? Yes No

If yes, explain

Language Spoken

Please list languages you speak and how well you speak them.

1.

2.

3.

Education

High School

Highest Grade Attended

Country

City

State

From

To

Did you graduate?

Yes

No

Degree

College

Country

City

State

From

To

Did you graduate?

Yes

No

Degree

Other

Country

City

State

From

To

Did you graduate?

Yes

No

Degree

Domestic Violence

Prevention of Medical Errors

Bloodborne Pathogens/ HIV-AIDS

Alzheimer's/ Dementia

Previous Employment

Company

Phone

Address

Supervisor

Job Title

Starting Salary: $

Ending Salary: $

Job Duties

From

To

Reason for leaving:

May we contact your previous supervisor for a reference?

Yes

No

Company

Phone

Address

Supervisor

Job Title

Starting Salary: $

Ending Salary: $

Job Duties

From

To

Reason for leaving:

May we contact your previous supervisor for a reference?

Yes

No

Company

Phone

Address

Supervisor

Job Title

Starting Salary: $

Ending Salary: $

Job Duties

From

To

Reason for leaving:

May we contact your previous supervisor for a reference?

Yes

No

References

Please list three references who are not related to you nor are they previous employers. Give name and addresses

1. Full Name:

Relationship

Phone

Address

2. Full Name:

Relationship

Phone

Address

3. Full Name:

Relationship

Phone

Address

Employment/Medical Documentation

Nursing License

Driver's License

SS Card

Physical Statement
(from within the last year) stating you are free from communicable disease

TB Skin Test (within 90 days) or Chest X-Ray (within 5 years)
(From within the last year)

Proof of Auto Insurance

Voided Check with Direct Deposit Form

2 Employment Verification's

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not intended to be a contract of employment. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I understand, also that I am required to abide by all rules and regulations of the company.

Applicant Signature

Date

Attach Resume:

Full time	Part time
Shift Work	Weekends Only
Temporary