State:
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Phone Number:

Email:

Date of Birth:

Which shift would you be interested in:

DayNightEveningW/E

Date Available

Do you have the legal right to remain in the US?

Yes, I am a citizen of the US.Yes, but I am not a citizen of the US.No

YesNo

Have you been convicted of a crime (excluding misdemeanors and traffic offenses) and/or released from confinement following a conviction for any criminal offense within the past 7 years?

YesNo

If so, give date, place, and nature of each such conviction:

Are you presently charged with any violation of the law other than a traffic violation?

YesNo

If so, give date, place, and nature of each such conviction:

Educational History, High School(Please indicate name and location of the school, Last Year Attended, Whether you graduated, and if you received a degree)

Educational History, College (Please indicate name and location of the school, Last Year Attended, Whether you graduated, and if you received a degree)

Educational History, Other (Please indicate name and location of the school, Last Year Attended, Whether you graduated, and if you received a degree)

List professional licenses you possess. Indicate type of license, number, and state:

List any memberships in professional organizations, honors, or activities which you feel would enhance your application, excluding those that would indicate race, color, religion, sex, national origin, or disability:

List languages spoken other than English:

List emergency contacts:

Work History

Last Company Name

Last Company Address (include City, State and ZIP Code)

Phone Number

Name of Supervisor

Date started:

Date left:

Type of salary

Part-timeFull-timePer Visit

OK to Contact Supervisor?

YesNo

Reason for Leaving

Personal References

List name, phone number, and relationship. Each reference should be on a new line.

Resume:

Cover Letter:

I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial, or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

I understand and agree that if I am offered employment by the facility, my employment will be for no definite term and that either I, or the facility will have the right to terminate the employment relationship at any time, with or without cause and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the facility.

I understand, that if I am an unlicensed person who has direct patient contact, that the agency will perform a criminal history check per State Regulations.

Release: I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.