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Application Form
Step
1
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2
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LOCATION
DATE
MM slash DD slash YYYY
PERSONAL INFORMATION
NAME
First
Middle
Last
OTHER NAME USED WHILE WORKING
ADDRESS
Street Address
City
State / Province / Region
ZIP / Postal Code
Email
HOME TELEPHONE NUMBER
ARE YOU A U.S. CITIZEN OR ARE YOU AUTHORIZED BY THE INS TO WORK?
YES
NO
HAVE YOU EVER BEEN GUILTY OR BEEN CONVICTED OF ANYTHING OTHER THAN TRAFFIC VIOLATIONS? IF YES, PLEASE EXPLAIN
SOME FACILITIES MAY HAVE SMOKE FREE ENVIRONMENTS, WOULD YOU AGREE TO WORK IN SUCH A FACILITY?
YES
NO
EMPLOYMENT DESIRED
HAVE YOU EVER APPLIED FOR EMPLOYMENT AT THIS OR OTHER PRIORITY MANAGEMENT FACILITIES BEFORE? IF SO, INCLUDE NAME(S) OF THE FACILITY(IES) AND DATES
IF YOU HAVE WORKED AT A NURSING FACILITY BEFORE, PLEASE LIST THE NAME(S) OF THE FACILITY(IES) AND THE DATES
DATE YOU CAN START
MM slash DD slash YYYY
STARTING SALARY DESIRED
POSITION DESIRED
SHIFT DESIRED
ANY SHIFT YOU ARE NOT WILLING TO WORK?
HAVE YOU EVER BEEN EXCLUDED FROM PARTICIPATING IN ANY FEDERAL OR STATE HEALTH CARE PROGRAM?
YES
NO
ARE YOU EMPLOYED NOW?
YES
NO
IF SO, MAY WE CONTACT YOUR EMPLOYER?
YES
NO
ARE YOU CURRENTLY ON LAYOFF OR LEAVE FROM ANOTHER COMPANY?
YES
NO
ARE YOU AVAILABLE FOR FULL TIME WORK?
YES
NO
ARE YOU AVAILABLE FOR PART TIME WORK?
YES
NO
LIST APPLICABLE SKILLS OR LICENSES
EDUCATION
HIGHEST GRADE OR DEGREE COMPLETED (LIST PARTIAL DEGREE ALSO)
NAME AND LOCATION OF LAST SCHOOL ATTENDED
ANY VOCATIONAL OR TRADE TRAINING?
LIST ANY ADDITIONAL SKILL, TRAININ, EXPERIENCE, OR OTHER QUALIFICATIONS RELATED TO THE POSITION WHICH YOU ARE APPLYING
REFERENCES
REFERENCE 1 - NAME
REFERENCE 1 - ADDRESS
REFERENCE 1 - PHONE
REFERENCE 1 - YEARS ACQUAINTED
REFERENCE 2 - NAME
REFERENCE 2 - ADDRESS
REFERENCE 2 - PHONE
REFERENCE 2 - YEARS ACQUAINTED
EMERGENCY (IN CASE OF EMERGENCY CONTACT)
EMERGENCY CONTACT - NAME
EMERGENCY CONTACT - ADDRESS
EMERGENCY CONTACT - PHONE
EMERGENCY CONTACT - RELATIONSHIP TO YOU
EMPLOYMENT HISTORY
NAME OF COMPANY 1
ADDRESS OF COMPANY 1
CONTACT PHONE NUMBER
DATES WORKED AT COMPANY 1
DESCRIBE THE WORK YOU DID
BEGINNING SALARY
ENDING SALARY
REASON FOR LEAVING
SUPERVISOR
ADDITIONAL EMPLOYMENT HISTORY (IF APPLICABLE)
NAME OF COMPANY 2
ADDRESS OF COMPANY 2
CONTACT PHONE NUMBER
DATES WORKED AT COMPANY 2
DESCRIBE THE WORK YOU DID
BEGINNING SALARY
ENDING SALARY
REASON FOR LEAVING
SUPERVISOR
NAME OF COMPANY 3
ADDRESS OF COMPANY 3
CONTACT PHONE NUMBER
DATES WORKED AT COMPANY 3
DESCRIBE THE WORK YOU DID
BEGINNING SALARY
ENDING SALARY
REASON FOR LEAVING
SUPERVISOR
NAME OF COMPANY 4
ADDRESS OF COMPANY 4
CONTACT PHONE NUMBER
DATES WORKED AT COMPANY 4
DESCRIBE THE WORK YOU DID
BEGINNING SALARY
ENDING SALARY
REASON FOR LEAVING
SUPERVISOR
PLEASE READ AND COMPLETE BEFORE SIGNING
ALL STATEMENTS MADE BY ME ON THIS APPLICATIONA RE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND THAT I HAVE WITHHELD NOTHING WHICH, IF DISCLOSED, WOULD AFFECT THIS APPLICATION UNFAVORABLY. I AGREE THAT THIS FACILITY AND MY PREVIOUS EMPLOYERS SHALL NOT BE HELD LIABLE IN ANY RESPECT IF A JOB OFFER IS NOT EXTENDED, IS WITHDRAWN, OR MY EMPLOYMENT IS TERMINATED BECAUSE OF FALSE STATEMENTS, OMISSIONS OR ANSWERS MADE BY ME ON THIS APPLICATION.
AGREE
DISAGREE
I AUTHORIZE MY PREVIOUS EMPLOYERS, SCHOOLS OR PERSONS NAMED AS REFERENCES TO GIVE ANY INFORMATION REGARDING EMPLOYMENT OR EDUCATIONAL RECORD
AGREE
DISAGREE
I UNDERSTAND THAT OPERATING CONDITIONS MAY REQUIRE ME TO TEMPORARILY WORK SHIFTS OTHER THAN THE ONE FOR WHICH I AM APPLYING AND I AGREE TO SUCH SCHEDULING CHANGES AS DIRECTED BY MY SUPERVISOR OR THE FACILITY ADMINISTRATOR.
AGREE
DISAGREE
IN THE EVENT OF MY EMPLOYMENT I AGREE TO COMPLY WITH ALL RULES AND REGULATIONS AS SET FORTH IN ANY COMMUNICATION DISTRIBUTED TO EMPLOYEES.
AGREE
DISAGREE
I AGREE TO PROVIDE THE REQUIRED DOCUMENTATION TO COMPLY WITH THE IMMIGRATION AND CONTROL ACT OF 1986 ON OR BEFORE THE FIRST DAY OF EMPLOYMENT.
AGREE
DISAGREE
I UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT IS "AT WILL" AND IF FOR NO DEFINITE PERIOD AND MAY BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE.
AGREE
DISAGREE
I AGREE AS A CONDITION OF INITIAL AND CONTINUED EMPLOYMENT, TO SUBMIT TO SUBSTANCE ABUSE TESTING (SUCH AS ALCOHOL, DRUGS, ETC) AT ANYTIME AT THE REQUEST ODF MY EMPLOYER AND I UNDERSTAND THAT REFUSAL TO SUBMIT TO SUBSTANCE ABUSE TESTING MAY BE GROUNDS FOR IMMEDIATE DISMISSAL..
AGREE
DISAGREE
CAN YOU PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITION FOR WHICH YOU ARE APPLYING?
AGREE
DISAGREE
SIGNATURE (PLEASE TYPE YOUR FULL NAME TO SIGN)
DATE SIGNED
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.
Home
About
News
Reviews
Gallery
Amenities
Rooms
Dining
Activities
Services
Short Term Rehabilitation
Skilled Nursing
Long Term Care
Outpatient Therapy
Dementia Care
Respite Care
Hospice/Palliative Care
Information for Families
Guide to Choosing A Care Facility
Financial Information
FAQ’s
Request A Tour
Careers
Contact
(985) 872-4553
Contact