Application for Employment Employment Affillable Date: MM slash DD slash YYYY Position applying for: Email: Name: Address:City / State / ZIP: Home telephone:Cell telephone:Please provide all names that you have used the past including maiden names, married names and/or aliases: Are you at least 18 years of age? Yes No Are you at least 16 years of age? Yes No If younger than age 16, can you furnish a work permit? Yes No Have you ever been employed here before? Yes No If yes, give date MM slash DD slash YYYY Are you employed now? Yes No May we contact your present employer? Yes No Can you, if hired, submit verification of your legal right to work in the U.S.? If hired, you will be required to submit documents sufficient to establish employment authorization and identity compliance with the Immigration Reform and Control Act of 1986 and all applicable regulations. While you need not provide this proof of legal status at the time you are interviewed, you will be required to do so after hire. Yes No On what date would you be available for work? MM slash DD slash YYYY Expected salary:Are you available to work: Full Time Part Time Occasional What days? Su M T W T F Sa What hours?: 6a-2p 2-10 10p-6a 6a-6p 6p-6a Are you on a layoff and subject to recall? Yes No Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime other than a simple misdemeanor offense relating to motor vehicles and laws of the road under chapter 321 or equivalent provisions, in this state or any other state? Yes No If yes, explain:Are there currently any criminal charges pending involving you, or are you under investigation for child or dependent adult abuse? Yes No If yes, explain:Have you ever been or are you currently excluded or debarred from participation in any Federal or State health care program, including Medicare or Medicaid? Yes No If yes, explain:Have you ever had a professional license (including nursing, administrator, physician, therapy, social worker, dietician) that was revoked, suspended, or voluntarily relinquished? Yes No If yes, explain: EDUCATIONSchool Name Elementary High School College/University Graduate/Professional Years Completed (enter year completed) Diploma/Degree Describe Course of Study: Do you hold any current licensure or registration? Yes No If yes, list:Have you ever had any disciplinary action taken against your license, including as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property? Yes No If yes, list:Educational honors; extra-curricular activities; professional societies or other information that you believe is related to your ability to perform the position for which you are applying and your application for employment: Special skills and qualifications, including those acquired from employment or other experience: EMPLOYMENT EXPERIENCEStart with your present or last job. Include military service assignments and/or volunteer activities. Account for all periods of unemployment. Employer TelephoneDates Employed From: MM slash DD slash YYYY To: MM slash DD slash YYYY Work performedAddressJob title Supervisor Hourly rate/Salary : StartingFinalReason for leaving Employer TelephoneDates Employed From: MM slash DD slash YYYY To MM slash DD slash YYYY Work performedAddressJob title Supervisor Hourly rate/Salary: StartingFinalReason for leaving If additional space is needed, please continue a blank space on the back of the application is available. State any additional information you feel may be helpful to us in considering your application. If additional space is needed, please continue a blank space on the back of the application is available. State any additional information you feel may be helpful to us in considering your application. Please list 2 work references or 3 personal references with contact information. APPLICANT’S STATEMENT PLEASE READ CAREFULLY BEFORE SIGNING I certify that the answers given in this Application for Employment are true and complete to the best of my knowledge. The facility may investigate all statements made in this Application. The facility is required by law to check for any criminal or abuse record. I understand that any false or misleading information provided can result in a decision not to hire; immediate discharge if hired, and civil or criminal penalties in appropriate cases. In signing this Application I state that I have received a copy of the Job Description for all jobs for which I have applied. I understand that I will be required to fulfill all aspects of any job if I am hired to perform the job. I understand that the failure to fulfill any aspect of the job may result in termination. I also understand that I may be required to take a physical examination conducted by a physician of the employer’s choosing after I am given a qualified offer of employment and that a health screening for diseases, such as TB, is required. I understand that this Application is not a contract of employment; that if hired, regardless of any oral representations to the contrary, the employment relationship between myself and the facility is terminable at will; that I have the right to terminate my employment at any time for any reason, and the facility retains the same right. Any changes to this employment relationship must be in writing. I understand that if hired I am required to abide by all rules and regulations of the facility. Signature of Applicant Witness AN EQUAL OPPORTUNITY EMPLOYER This facility is an equal opportunity employer. Employment decisions are made without regard to age, race, creed, color, sex, sexual orientation, gender identity, national origin, religion, disability, status as a disabled Vietnam era veteran, or other category as specified by law.
