Wauneta Care and Therapy Center Employment Application

Employment Application

APPLICANT INFORMATION

Last Name

First

M.I.

Date

Street Address

Apartment/Unit

City

State

ZIP

Phone

E-mail Address

example@example.com

Date Available

Date

Social Security No.

Desired Salary

Position Applied for

Are you a citizen of the United States?

YES NO If no, are you authorized to work in the U.S.? YES NO

Have you ever worked for this company?

YES NO

Have you ever worked for this company?

Have you ever been convicted of a felony? YES NO

If so, when?

If yes, explain

EDUCATION

High School

Address

From

To

Did you graduate? YES NO

Degree

College

Address

From

To

Did you graduate? YES NO

Degree

Other

Address

From

To

Did you graduate? YES NO

Degree

REFERENCES

Please list three professional references.

Full Name

Relationship

Company

Phone

Address

Full Name

Relationship

Company

Phone

Address

Full Name

Relationship

Company

Phone

Address

PREVIOUS EMPLOYMENT

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

YES NO

NO

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

YES NO

NO

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

YES NO

NO

MILITARY SERVICE

Branch

From

To

Rank at Discharge

Type of Discharge

If other than honorable, explain

PROFESSIONAL LICENSED OR CERTIFIED PERSONNEL

Are you registered in Nebraska? Yes No License #:

PROFESSIONAL LICENSED OR CERTIFIED PERSONNEL

I f not Nebraska registered, have you applied for reciprocity? Yes No

License #:

Type of Discharge

If other than honorable, explain

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature

Date

I CERTIFY AND AGREE AS FOLLOWS:

That this application will remain active for 30 days. If I would like to be considered for employment after 30 days, I will need to complete a new application. That evidence of false statements or incomplete information on this application will be considered sufficient cause for immediate discharge if already employed. That nothing contained in this application or in the interview process is intended to create an employment contract between Wauneta Care & Therapy Center and myself. I understand that I have the right to terminate my employment at any time with or without notice or reason and that Wauneta Care & Therapy Center retains a similar right. If selected, I will obtain an employment physical or screening, performed by a qualified staff member of Wauneta Care & Therapy Center or paid for by Wauneta Care & Therapy Center. If a screening is done at Wauneta Care & Therapy Center and the qualified staff member feels it is necessary for me to see a physician for further testing, Wauneta Care & Therapy Center will pay for that visit and the physician must certify that I am able to work before I actually begin my employment. If my job requires certification and/or education requirement, I am willing to complete the course and testing in a timely manner. I understand that Wauneta Care & Therapy Center is an Equal Opportunity Employer. All qualified persons are welcome to submit applications for employment. Applicants will be selected solely on qualification, without regard to race, color, creed, national origin, sex, pregnancy, genetics, disability, age, religion, marital status, or ancestry.

Clear

SIGNATURE:

DATE:

Date

REFERENCE CHECK

I consent to having Wauneta Care & Therapy Center contact anyone that it deems appropriate to investigate or verify any information I have given or to discuss my background, past performance, or suitability for employment. I further consent to being discussed by any person so contacted and I wave all rights to bring any action for defamation, invasion of privacy, or any similar cause against anyone contacted as a result of what he or she may say about me. I also Understand that Wauneta Care & Therapy Center will check to determine if there is a history of past abuse of any residents.

I authorize Wauneta Care & Therapy Center to release specific employment information to places where I have filed an employment application, whether during or after my employment with Wauneta Care & Therapy Center.

SIGNATURE:

Clear

DATE:

Date

427 West Legion Street P O Box 520 Wauneta, NE 69045 (308) 394-5738 Fax: (308) 394-5733

WAUNETA CARE & THERAPY CENTER

PLEASE READ AND SIGN BELOW: