Employee Application

Please read carefully.

Position Applying For*
Last Name*
First Name*
Middle Name
Email*
Soial Security #
Home Telephone #
Cell #
Street Address
City
State
Zip Code
County
How did you hear about our company
Are you applying for (Check all that apply)*
- Full-Time
- Part-Time
- Per Diem
- Temporary
Date available to work*
Have you ever worked for any of our facilities?*
- Yes
- No
- Dont Know
Location
If you have, are you eligible for rehire?*
- Yes
- No
Weekends and holidays?*
- Yes
- No
Rotating Shifts?*
- Yes
- No
On Call?*
- Yes
- No
If not a U.S. citizen, are you legally uthorized to work in the U.S.?*
- Yes
- No
- N/A
Have you ever been convicted of any crime?*
- Yes
- No
If yes, which state and what year? Please explain:
Have you ever been accused of any type of abuse?*
- Yes
- No
If yes, Please explain:
Education / Skills
High School
Name and Address of School Course of Study Last Year Completed Graduate?
College
Name and Address of School Course of Study Last Year Completed Graduate?
Other
Name and Address of School Course of Study Last Year Completed Graduate?
List Healthcare, Business or Industrial Equipment Operated
Professional Licenses and/or Certification
You are currently?*
- Registered
- License
- Certified
Eligible for?*
- Registration
- License
- Certification
Information Here
Type States Issued or Application Made Date Issued or Application Made Number
Previous Residence (Begin with most recent address, not including current address)
Previous Address City State Zip Code Dates

We are an equal opportunity employer and we do not discriminate on the basis of race, color, age, religion, sex, national origin, disability or veteran status.
Previous Employment (begin with most recent employer)
Employer Name #1*
From - To*
Last Pay*
Address
Immediate Supervisor
Phone
Job Title
Duties
Reason for Leaving
If current employer, may we contact?
- Yes
- No
Employer Name #2
From - To
Last Pay
Address
Immediate Supervisor
Phone
Job Title
Duties
Reason for Leaving
Employer Name #3
From - To
Last Pay
Address
Immediate Supervisor
Phone
Job Title
Duties
Reason for Leaving
Describe Any Other Relevant Experience
References (supply at least three references who are not relatives)
Name Title, If Any Company Name and Address Telephone
Certification And Acknowledgement (Please read carefully and sign)

I certify that all information I have provided on this application and on any accompanying documents is true and correct. I understand that any false statement I have made herein or my failure to disclose requested information may disqualify me from consideration for employment or, if employed, may result in my termination.

*I hereby authorize this facility, its agents and employees to contact any reference provided by me during the application process, and I authorize all references so contacted to release any information about me that they may have. I further authorize this facility or its agent to perform an investigation of local, state and federal records relating to any criminal convictions I may have. I further understand that any offers of employment are contingent upon a satisfactory criminal background investigation. An applicant is not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to section 46b-146, 56-76o or 54-142a. Criminal records subject to erasure pursuant to section 46b-146, 56-76o or 54-142a or 54-142a are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty or a conviction for which the person received an absolute pardon. Any person whose criminal records have been erased pursuant to section 46b-146, 56-76o or 54-142a or 54-142a shall be deemed to have never been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so swear under oath. I release this facility and any references contacted by this facility from any and all liability that may result from any investigation or reference check.

*I understand and acknowledge that I have not been convicted of an offense that would preclude me of employment or working in a nursing home facility and that I am not excluded from participation in the Federal and State Health Care Programs.

*I understand and acknowledge that I may be required to undergo a post-offer, pre-employment physical exam and a post-offer, pre-employment drug screening analysis for substance abuse. I understand that the result may, to the extent permitted by law, result in the revocation of any offer of employment. I understand and acknowledge that nothing contained in this application or in any interview which I may be granted is intended to create a contract of employment between this facility and me. I further understand and acknowledge that, if I am offered a position with this facility, my employment may be terminated at any time, without notice or cause, except as otherwise provided by law.
Signature
Date
Phone
This field is for validation purposes and should be left unchanged.

Employee Application

Education / Skills

Professional Licenses and/or Certification

Previous Employment (begin with most recent employer)