Careers

Personal Background

Last Name First Name Middle Initial Date of Birth(MM/DD/YYYY)

Maiden (or other name formerly used) Date last used(MM/YYYY)

Current Address Address Line 2

City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip County

Home Phone Cell Phone Email Address

Marital Status: Single  Married  Widowed  Divorced

Are you subject to any city or local income taxes? Yes  No

If yes, please specify:

Employment Desired

Date available Salary Desired

Are you presently employed? Yes  No Are you over the age of 18?Yes  No

Are you legally authorized to work in the United States without restriction? Yes  No
(Proof of identity and employment eligibility will be required upon hire.)

If employment is offered, do you intend to have any type of secondary employment or self-employment? Yes  No

Have you ever applied to this company or any of its affiliates? Yes  No
If yes, when? Which affiliate(s)?

Have you ever been employed by this company or any of its affiliates? Yes  No
If yes, when? Which affiliate(s)?

Do you have any relatives employed by this company? Yes  No
If yes, who and what location?

Emergency Contact Information

Emergency Contact Name Relationship

Emergency Contact Home Phone Work Phone

Availability Record

Please indicate your availability:

If required, would you be willing to work
Overtime Yes  No       Holidays Yes  No       Saturdays/Sundays Yes  No       Rotating Shifts Yes  No      

Can you and are you willing to travel if your job requires it? Yes  No

Education and Training

Indicate the highest level of education completed:

High School 9  10  11  12College/University 1  2  3  4

Technical/Trade School 1  2  OtherGraduate School   1  2  3

Computer Skills (list software)

Other machines, trades, special skills or qualifications

Professional Licenses and/or Certifications

Has your license/certification ever been revoked? Yes  No
Do you have a license that is not currently valid? Yes  No If yes, please explain:

Previous Residences

List the city, country and state of all your previous residences in the last seven years (use additional sheet if necessary)

Criminal Record

Have you ever been convicted of or plead guilty to a misdemeanor or felony? Yes  No
If yes, please indicate:
Date Location (City/State) Charge Action Taken
(Note: You are not required to provide information on any expunged or sealed record.)

Have you ever been convicted of an offense which would preclude employment in a nursing facility? Yes  No If yes, please indicate:
Date Location (City/State) Charge Action Taken (Note: You are not required to provide information on any expunged or sealed record.)

Illegal Use of Drugs

Do you currently engage in the illegal use of drugs (marijuana, cocaine, heroin, LSD, etc.)? Yes  No

Are you willing to be tested for the illegal use of drugs? Yes  No

Employment History

Listing the most recent position first, provide the following information regarding your previous employment. Please complete all of the employment history even though some or all of the information may be on your resume.

Are you currently bound by any employment agreement or non-compete agreements? Yes  No
If yes, please list:

CompanyPhone
Type of Business City State
Employed: From (MM/YY) To (MM/YY) Your Exact Title/Position
Base Salary: Start End Other Compensation
Supervisor's Position Immediate Supervisor
Reason for Leaving May we contact? Yes  No
Description of duties, responsibilities and accomplishments

CompanyPhone
Type of Business City State
Employed: From (MM/YY) To (MM/YY) Your Exact Title/Position
Base Salary: Start End Other Compensation
Supervisor's Position Immediate Supervisor
Reason for Leaving May we contact? Yes  No
Description of duties, responsibilities and accomplishments

CompanyPhone
Type of Business City State
Employed: From (MM/YY) To (MM/YY) Your Exact Title/Position
Base Salary: Start End Other Compensation
Supervisor's Position Immediate Supervisor
Reason for Leaving May we contact?Yes  No
Description of duties, responsibilities and accomplishments

CompanyPhone
Type of Business City State
Employed: From (MM/YY) To (MM/YY) Your Exact Title/Position
Base Salary: Start End Other Compensation
Supervisor's Position Immediate Supervisor
Reason for Leaving May we contact?Yes  No
Description of duties, responsibilities and accomplishments

References

Please list three individuals whom you have known for at least three years, other than relatives; at least two references should be business related.

NameTitle
CompanyBusiness Address
Business PhoneRelationship

NameTitle
CompanyBusiness Address
Business PhoneRelationship

NameTitle
CompanyBusiness Address
Business PhoneRelationship

Have you ever been terminated from employment or asked to resign by an employer? Yes  No
If yes, please list:

Resume

Attach your resume (2MB filesize limit):

Please read carefully before submitting.

This is an equal opportunity employer. I understand that no question being asked as part of my consideration for employment is intended to be unlawful. I understand that this application does not create a contract of employment. I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation by the Employer to hire me. If I am hired, I understand that either the Employer or I can terminate my employment at any time and for any reason.

All of the information I have given to the Employer in considering me for employment is truthful. No other information has been concealed or intentionally omitted. I understand that the Employer may decide to conduct drug screenings and criminal background checks. I authorize, to the fullest extent permitted by law, any such drug screening and/or criminal background check as well as the investigation of all other matters concerning my consideration for employment. I understand that all offers of employment are contingent upon the receipt of a favorable result of any such drug screening, criminal background check and other investigated matter. I authorize the Employer to conduct the screening, background check or investigation directly or through its agents, and further authorize my former employers, references, physicians, and acquaintances to give any such information they may have regarding me. I release and indemnify this Employer, as well as any parties from whom information is obtained, from any liability whatsoever resulting from the drug screening, criminal background check or any other investigation and release of this information. If any information I have given to the Employer is untrue or misleading, if I have concealed any information, or adverse information is discovered through the investigation, I understand that this may result in the denial of employment, revocation of an offer of employment, or termination of employment.

In compliance with the Immigration Reform and Control Act of 1986, I understand that I will be required to provide approved documentation that verifies my right to work in the United States on my first day of employment.

Although management makes every effort to accommodate individual preference, business needs may at times make the following conditions mandatory: overtime, change in work location, a rotating work schedule, or a work schedule other than Monday through Friday. I understand and accept these as conditions of my continuing employment. Additionally, I am aware that my employment is contingent on operational requirements.