| Physician's
Name: Address: |
Is
there any reason why you would be unable to perform any of the duties of
the
position for which you are applied?: Yes:
No: |
Have
you ever been convicted in a court of law for other than traffic
violations?:
Yes:
No: |
| If
Yes, List Convictions:
Dates: |
| Have
you ever applied for work at this nursing home before?: Yes:
No: |
| Source
of Referral (Please Specify): |
|
Military Status |
| Have
you ever been a member of the military services?: Yes:
No: |
| If
Yes, Branch: Rank at Discharge:
|
| Date
Entered: Date
Discharged: |
Special
Skills Acquired:
|
|
Educational
Background |
| Select
Highest Grade Completed: |
| High
School: Address: Zip Code: |
| Course
of Study: |
| Dates
Attended - From: To:
Did you Graduate?: Yes:
No: |
| College,
University or Professional, Vocational Technical, Business: |
| Address:
Zip Code: |
| Course
of Study: |
| Dates
Attended - From: To:
Did you Graduate?: Yes:
No: |
List
any special skills you may have (school honors, clerical, secretarial,
etc.:
|
Additional
Comments:
|
| Professional
Registration or Licensure: |
| Type:
State:
#: |
Additional
Remarks:
|
|
References |
| List
three names who are not former employers or relatives: |
| Name:
Address:
City: |
| Name:
Address:
City: |
| Name:
Address:
City: |
|
Work History |
| List
your work experience for the past (10) ten years BEGINNING WITH YOU MOST
RECENT POSITION: |
| Name
& Address: |
| Nature
of Experience: |
| From:
To:
|
| Cash
Salary: Other Compensation: |
| Reason
for Leaving: |
| Name
& Address: |
| Nature
of Experience: |
| From:
To:
|
| Cash
Salary: Other Compensation: |
| Reason
for Leaving: |
| Name
& Address: |
| Nature
of Experience: |
| From:
To:
|
| Cash
Salary: Other Compensation: |
| Reason
for Leaving: |
| Name
& Address: |
| Nature
of Experience: |
| From:
To:
|
| Cash
Salary: Other Compensation: |
| Reason
for Leaving: |
| May
we contact your current employer?: Yes:
No: |
|
|
The facts set forth in this application
for employment are true and complete. False information on this
application shall be sufficient cause for non-consideration for
employment or for dismissal after employment. I also recognize that my
employment is based on receipt of satisfactory information from former
employers and references, and upon my ability to pass a physical
examination. I herein authorize the administration of this institution
to investigate without liability the information supplied by me in this
application for employment including academic, occupational, health,
police, and governmental records. I also authorize listed employers and
references without liability to make full response to any inquiries by
the administration of this institution in connection with this
application for employment. Further, If employed, I agree to work the
hours, days and shifts as scheduled. I will share weekend and holiday
coverage. I will work in another department if requested to do so.
I further certify that I have read the
foregoing paragraph and knowingly make this authorization by typing YES
Date:
|
|
Your application is valid for a period of
thirty(30) days. If you wish to be considered thereafter, you must
physically reapply for employment at the personnel office.
|
| |
|
