Employment Application
Roselani Place
Your Name
*
First Name
Last Name
Date of Application
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
*
Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Are You Authorized to Work in the U.S.?
*
Please Select
Yes
No
Alternate Phone Number
*
Please enter a valid phone number.
Position for Which You are Applying:
*
Are You at Least 18 Years of Age?
*
Please Select
Yes
No
Do You Wish to Full Time or Part Time
*
Full Time
Part Time
If Part-time, Specify Hours and Days
Availability (check all that apply)
*
Weekdays
Weekends
Days
Nights
Evenings
Holidays
Overtime
For Care Staff, What Shift are You Applying for?
Day Shift (6am-2pm)
Evening Shift (2pm-10pm)
Night Shift (10pm-6am)
Minimum Hourly Wage Requirement
*
Date Available for Work
*
-
Month
-
Day
Year
Date
Driver's License #
*
Expiration Date
*
-
Month
-
Day
Year
Date
Has Your Driver's License in Any State Ever Been Denied, Surrendered, Suspended, Revoked, Restricted or Investigated?
*
Please Select
Yes
No
If Yes, Please Explain
Professional License Type:
Professional License #:
Professional License Expiration Date:
-
Month
-
Day
Year
Date
Professional License State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
GU
MH
MP
PR
VI
Has This License in Any State Ever Been Denied, Surrendered, Suspended, Revoked, Restricted, Investigated or Been Placed on Probation?
Yes
No
If Yes, Please Explain
Have You Ever Had any Claims, Judgements, Compensation for Injury, or Settlements Made Against You in a Professional Liability Case at any Time During Your Professional Practice?
Yes
No
If Yes, Please Explain
How Did You Hear About Us?
*
Do You Currently Suffer from Any Illness, Injury, Health Condition (Physical or Mental) or Contagious Disease Which Would Impair Your Current Ability to Safely Carry Out the Responsibilities of the Position for Which You Are Applying? If Yes, Please Explain:
*
Except for Vacations and Holidays, How Many Work Days Were You Absent During the Current Calendar Year?
*
0-5 Days
5-10 Days
10-15 Days
15-20 Days
21+ Days
During the Prior Calendar Year?
*
0-5 Days
5-10 Days
10-15 Days
15-20 Days
21+ Days
Please Explain Absences Over 5 Days for Each Year:
Did You Receive any Verbal Warnings, Written Warnings, or Other Disciplinary Actions Concerning Your Performance of Your Job Responsibilities at any of Your Previous Jobs?
*
Please Select
Yes
No
If Yes, Please Explain
Have You Previously Applied for Employment Here?
*
Please Select
Yes
No
If Yes, When?
Have You Previously Been Employed by This Property, or any of Its Affiliated Properties?
*
Please Select
Yes
No
If Yes, When?
Are any of Your Relatives Employed Here or at any Affiliate?
*
Please Select
Yes
No
If Yes, Please List Name(s) and Property(s)
Do You Expect to Also Work Elsewhere (Full or Part-time) if Employed Here?
*
Please Select
Yes
No
If Yes, Please Explain
Have You Ever Been Convicted of a Criminal Offense (Felony or Misdemeanor)?
*
Please Select
Yes
No
*An affirmative answer will not automatically disqualify you from being considered as a candidate for employment.
If Yes, Date of Conviction?
-
Month
-
Day
Year
Date
If Yes, Nature of Conviction
In Order to Permit a Check of Your Work and Education Records, Please Indicate any Names You Have Used in the Past and Relative Date(s):
*
If none, please mark "None"
Education
High School Info
High School Name
High School City and State
Number of Years Completed
Degree or Certificate
Subjects Studied
College Info
College Name
College City and State
Number of Years Completed
Degree or Certificate
Subjects Studied
Other School
Other School Name
Other School City and State
Number of Years Completed
Degree or Certificate
Subjects Studied
Employment History
Most Recent Employer
Most Recent Employer Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Employment Start (Mo/Yr)
Employment End (Mo/Yr)
Starting Salary
Final Salary
Supervisor Name
Starting Position
Last Position
Other Positions Held
Duties
Reasons for Leaving
Reason required why you resigned or were terminated
Employer 2
Employer Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Employment Start (Mo/Yr)
Employment End (Mo/Yr)
Starting Salary
Ending Salary
Supervisor Name
Starting Position
Last Position
Other Positions Held
Duties
Reasons for Leaving
Reason required why you resigned or were terminated
Employer 3
Employer Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Employment Start (Mo/Yr)
Employment End (Mo/Yr)
Starting Salary
Ending Salary
Supervisor Name
Starting Position
Last Position
Other Positions Held
Duties
Reasons for Leaving
Reason required why you resigned or were terminated
Personal/Professional References
Reference 1
Reference 1 Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relation
Reference 2
Reference 2 Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relation
Reference 3
Reference 3 Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relation
Agreement
Signature
*
Clear
Date of Signature
-
Month
-
Day
Year
Date
Preview PDF
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