Contact Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
Cell Phone
Work Phone
E-mail
example@example.com
Current Job Opening Interested In:
Nursing RN/LPN
Nursing LNA
Position applied for:
FT
PT
Per Diem
Days
Evenings
Nights
Date available to start work:
*
-
Month
-
Day
Year
Are you over the age of 18?
*
YES
NO
Have you applied to work with us before?
YES
NO
If yes, when?
Are you willing to work an irregular schedule, weekends, overtime, holidays or different shifts if necessary?:
YES
NO
If NO, Please Explain:
How did you hear about us?
Education
Employment History
(List most recent employment first.)
Employment #1 - Most Current
Employment #2
Employment #3
Professional References
(Please provide three)
Reference #1
Reference #2
Reference #3
United States Military Service
Thank you for your service!
Other Experience
Other relevant experience or qualifications:
Background
Have you ever:
Been found guilty of abusing, neglecting, exploiting or mistreating a nursing home resident by a court of law; or
Had a finding entered into the Vermont State Nurse Assistants Registry or the Vermont Adult Abuse Registry concerning abuse, neglect, exploitation or mistreatment of residents or misappropriation of their property?
Been convicted of a crime?
If YES, please explain:
Are you prevented from becoming lawfully employed in this country by your Visa or Immigration status? If YES, please explain:
In case of an Emergency
Emergency Contact:
Emergency Phone:
Relationship to you:
CERTIFICATION & AUTHORIZATION
I certify that all facts I have stated in this Employment Application are true and complete and I acknowledge that Mertens House is relying on the accuracy of the information provided in making a hiring determination. I authorize Mertens House to verify the accuracy of the information provided herein, and I authorize former employers, educational institutions and credit agencies to release information concerning me to Mertens House. I also authorize Mertens House to give references and provide information about me in response to inquiries subsequent to my employment if I am hired. I understand that falsification, misrepresentation or omission of requested facts may result in denial of employment or, if I am employed by Mertens House, may result in immediate dismissal. I understand and agree that if I am hired, my employment will be for no definite period and may, regardless of the date of payment of wages, be terminated at any time without notice and with or without reason, by me or by Mertens House. I also understand and agree that no one has authority to promise me job security or continued employment except the Administrator at Mertens House in a formal written agreement signed by both of us.
Signature of Applicant (Sign Here With Your Mouse):
Today's Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
Submit
Should be Empty: