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Application for Employment

Employment Opportunities: RNs LPNs and CNAs

Name First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Email
Date Available for Work / MM / DD YYYY
Phone -
Preferred Position
Preferred Wage
Date Available for Work:
Preferred Shift or Schedule
Are you legally eligible for employment in this country (US citizen or Alien authorized to work in the US?
Are you at least 18 years of age?
Are you currently using a controlled substance?
Have you ever been convicted of a crime, including felonies and misdemeanors, or have unresolved criminal matters?
If so, please explain:
Do you have an allergy to latex?
Have you ever worked here or at an affiliated location?
What location or affilliated company?
Are any of your relatives employed by this company?
Who is the relative and what relationship?
Name, Address, Phone of Employer 1
Position at Job 1
Start Date Job 1 / MM / DD YYYY
End Date Job 1 / MM / DD YYYY
Rate of Pay at Job 1
Supervisor at Job 1
Reason for Leaving Job 1 (if no longer at position)
Name, Address, Phone of Employer 1
Position at Job 2
Start Date Job 2 / MM / DD YYYY
End Date Job 2 / MM / DD YYYY
Rate of Pay at Job 2
Supervisor at Job 2
Reason for Leaving Job 2(if no longer at position)
Name, Address, Phone of Employer 1
Position at Job 3
Start Date Job 3 / MM / DD YYYY
End Date Job 3 / MM / DD YYYY
Rate of Pay at Job 3
Supervisor at Job 3
Reason for Leaving Job 3 (if no longer at position)
Reference 1 - Please provide: Name, Address, Contact Number, Contact Fax, and Relationship
Reference 2 - Please provide: Name, Address, Contact Number, Contact Fax, and Relationship
Reference 3 - Please provide: Name, Address, Contact Number, Contact Fax, and Relationship
High School Education Information: (Location, Course of Study, Graduation Date, Diploma or GED)
College Education Information: (College, Location, Major, Graduation Date, Degree Acheived)
Other School: (Location, Major or Course of Study, Graduation Date, Diploma/Degree/Certificate)
Licenses and Certifications: (Please list all including: State, Number, Expiration Date)
Application Statement:
I hereby affirm that the information provided on this application (and accompanying resume if applicable) is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me fom further consideration for employment and may result in discharge even if discovered at a later date. I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment. I also understand that employment may also be conditioned upon outcome of a criminal background check and reference checks completed by this company or its associates. I hereby authorize persons such as schools, my current employer, previous employers and other organizations to provide this company and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information. I understand that my employment is at will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the company has the same right. I understand that no one has the authority to enter into any agreement contrary to the proceeding sentence.
Digital Signature - Please Type In Your Whole Name
Date of Submission (Today) / MM / DD YYYY

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