Employment Application

Applicants will receive consideration without discrimination because of race, creed, color, sex, age, national origin, disability, religion, marital status, sexual orientation, status with regard to public assistance, military/veterans status or any other protected classes as defined by law.

Personal Information

First Name	Middle Initial	Last Name

Address	Address 2

City	State	Zip Code

Phone (xxx-xxx-xxxx)	Emergency Contact Number (xxx-xxx-xxxx)	Primary Email (xxx@xxx.xxx)
		Email Addresses MUST be valid.

Job Information

What position are you applying for?	What type of care facility would you prefer to work?

What is the best time to contact you?

Do any friends/relatives work here?	If yes, please name them.

Are you currently employed?

Are you eligible for employment in the United States?
Proof of citizenship or Immigration status will be required upon request.

When would you be available to start? (mm/dd/yy)	What is your desired pay range?
Dates MUST be in 'mm/dd/yy' format.

Are you available to work...
Full Time (indicate shift)	First Second Third
Part Time (indicate shift)	First Second Third
Temporary (list dates)	From (mm/dd/yy) Dates MUST be in 'mm/dd/yy' format. To (mm/dd/yy) Dates MUST be in 'mm/dd/yy' format.

Education

What is the highest grade you have completed?

Graduation Date (mm/yy)

Licensure/Certification. State Current

Please describe any specialized training, apprenticeship, and skills.

Please summarize any other special qualifications or skills aquired from employment or other experience.

Employment History

Most Recent Employer

Employed (mm/dd/yy)

From to Currently Employed here

Company Name	Employment Type

Address

City	State	Zip

Reason for leaving?

Position Held

Please describe the work performed.

Second Most Recent Employer

Employed (mm/dd/yy)

From to Currently Employed here

Company Name	Employment Type

Address

City	State	Zip

Reason for leaving?

Position Held

Please describe the work performed.

Third Most Recent Employer

Employed (mm/dd/yy)

From to Currently Employed here

Company Name	Employment Type

Address

City	State	Zip

Reason for leaving?

Position Held

Please describe the work performed.

- Required	I certify that the answers provided in this application are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
- Required	I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the facility retains the right to terminate employment at any time. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. I understand that this application is not a contract of employment; that if hired, regardless of any oral representation to the contrary.
- Required	In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Employment Application

Personal Information

Job Information

Education

Employment History

Second Most Recent Employer

Third Most Recent Employer

Equal Opportunity, Affirmative Action Voluntary Self Identification Form