Employment Application

Application for Employment

Name*
First Middle Last
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Email
Employment Preferences
Position Desired
How did you learn of this opening?*
- Careerbuilder.com
- Monster.com
- Facebook Ad
- Newspaper
- Indeed.com
- Current Employee
- Walk-In
- Other
If referred by a current employee what is their name?
Are you related to anyone working in the facility?
What is your ideal shift preference?*
What is your second choice for shift preference?*
Are you currently employed?*
May we contact your present employer?
Education and Training
Name of high school attended:*
Did you graduate or obtain GED?*
Do you have a degree from a college, university, or vocational school?*
If yes, what was your area of study and what degree did you earn?
Do you hold a professional license or certification?*
If yes, indicate type of license, organization or state issued by, issued date, and license/certification number for all licenses/certifications held:
Employment History
Most Recent Employer
Employer
Address
City State
Employer Phone #
Supervisor Name
First Last
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
Ending Salary
Position
Reason for Leaving
Second Most Recent Employer
Employer
Address
City State
Employer Phone #
Supervisor Name
First Last
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
Ending Salary
Position
Reason for Leaving
Third Most Recent Employer
Employer
Address
City State
Employer Phone #
Supervisor Name
First Last
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
Ending Salary
Position
Reason for Leaving
References
Reference 1 Name*
First Last
Phone*
Relationship*
How long have you known?*
Reference 2 Name*
First Last
Phone*
Relationship*
How long have you known?*
Reference 3 Name*
First Last
Phone*
Relationship*
How long have you known?*
Background Information and Consent
Have you ever been convicted of a crime or any of the following?*
(A sex crime; exploitation of an endangered adult; failure to report battery; neglect, or exploitation of an endangered adult; murder; voluntary manslaughter; involuntary manslaughter [within the past 5 years]; felony battery [within the last 5 years]; a felony offense related to controlled substances [within the past 5 years]; theft [within the past 5 years]; abused, neglected, or mistrated a patient; misappropriated the property of a patient; or had a finding entered into the state nurse aid registry.)
Have you ever been known by another name?*
If yes to the above, what was the name(s)?
Consent*
- I consent and acknowledge the statement below.
This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination. I voluntarily give this institution the right to make a thorough investigation of my past employment and activities. I agree to cooperate in such investigation and release from all liability or responsibility all persons, companies, or corporations supplying such information. I consent to take the pre-employment physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time with or without cause. I also understand that my employment may be terminated for any false statement or omission in face appearing on this application form. If employed, I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory evidence of identity and eligibility for employment.
Electronic Signature*
First Middle Last
This electronic signature will be seen as an official signature.
Resume Upload (Optional)
Cover Letter Upload (Optional)

Application for Employment

Employment Preferences

Education and Training

Employment History

Most Recent Employer

Second Most Recent Employer

Third Most Recent Employer

References

Background Information and Consent