Job Application

Full Name*

First NameMiddle NameLast Name

Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Email Address*

Phone Number*

Area CodePhone Number

Position Applying For*

Professional License #

Type of employment desired*

Full-TimePart-TimePRN

What is your desired salary?

Are you a citizen of the United States?

YesNo

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

YesNo

Have you ever worked for this company before?

YesNo

Most positions require every other weekend scheduling- is this a problem for you?

YesNo

Are you available to work:

6am-2pm2pm-10pm10pm-6am

If hired, can you submit verification of your legal right to work in the U.S. in compliance with the Immigration Reform and Control Act of 1986?*

YESNO

By selecting yes, you understand that Federal and State Law requires all potential employees to have a background check and Dependent Adult Abuse Check, which may also include certification or licensure check.

YesNo

Highest Level of Eduction

Did you graduate?

YesNo

May we contact your professional references?

YesNo

Reference 1: (Name, Company, Relationship, Phone Number, Email)

Reference 2: (Name, Company, Relationship, Phone Number, Email)

Reference 3: (Name, Company, Relationship, Phone Number, Email)

EMPLOYMENT UNDERSTANDING DISCLAIMER

THIS INSTITUTION DOES NOT DISCRIMINATE IN HIRING ON THE BASIS OF RACE, COLOR, RELIGION, SEX, SEXUAL ORIENTATION, GENDER IDENTITY, AGE, CITIZENSHIP, NATIONAL ORIGIN, ANCESTRY, VIETNAM ERA VETERAN STATUS, OR ON THE BASIS OF PHYSICAL OR MENTAL DISABILITY UNRELATED TO THE ABILITY TO PERFORM THE WORK REQUIRED. NO QUESTION ON THIS APPLICATION IS INTENDED TO SECURE INFORMATION TO BE USED FOR SUCH DISCRIMINATION.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examinations as may be required by this institution at such times and places as the institution shall designate.

I understand that an offer of employment may be contingent on passing physical examination which relates to the essential duties I would be required to perform.

I understand that the employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

I understand, if employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.

INVESTIGATION INFORMATION RELEASE AUTHORIZATION

I understand that Stacyville Community Nursing Home requires a thorough pre-employment background investigation. This investigation is limited to only information required to determine fitness for employment and may include, but is not limited to: employment history verification, job performance, disciplinary record, and a criminal background investigation. By signing this document, I agree to hold harmless any previous employer, agent of that corporation, or any individual or organization providing information pursuant to this Authorization.

I hereby certify that I have not been convicted and/or found guilty of resident or patient abuse, neglect or mistreatment, or of misappropriation of resident or patient property in this state or in any state, and that I am not listed in any resident or patient abuse registry in this state or in any state (unless disclosed on this application).

I understand that any offer of employment that is extended to me by Stacyville Community Nursing Home is conditional upon the verification of this information with the state abuse registry and that a listing in such registry or the registry of any other state may act as an automatic withdrawal of any such offer of employment.

I further understand that if I am applying for a licensed or certified position, any offer of employment by Stacyville Community Nursing Home is conditional upon verification of my license or certification with the appropriate state agency. In the event that I have not yet been so licensed or certified and in the event that I am offered employment with Stacyville Community Nursing Home, I agree to undertake the required training and competency certification requirements immediately upon commencing employment.

I understand, if this application leads to employment, any false or misleading information in my application or interview may result in my job termination.

I certify that my answers are true and complete to the best of my knowledge.

Signature*