Sacred Heart Care Center Application Form

Sacred Heart Care Center Application Form
Today's Date*

MonthDayYear
Date
Full Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What position are you applying for?*
On what date would you be available for work?*

MonthDayYear
Date
Are you available to work: (Check all that apply)*

DaysEveningsNights
Were you referred by a current or former employee of Sacred Heart?*

YesNo
If yes, please provide the employee's name:
Employment Experience

List below your work experience; Starting with your present or last place of employment.
Name and Address of Employer
Position
Dates Employed

MonthDayYear
Start Date
Dates Employed

MonthDayYear
End Date
Name and Address of Employer
Position
Dates Employed

MonthDayYear
Start Date
Dates Employed

MonthDayYear
End Date
Name and Address of Employer
Position
Dates Employed

MonthDayYear
Start Date
Dates Employed

MonthDayYear
End Date
May we contact your present employer at this time?

YesNo
Education
Highest level of education?
School/University Name:
Degree or Certificate:
Field of Study:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
References
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Applicant Statement

I certify that the information provided in this application is true and complete to the best of my knowledge. I authorize this organization to contact any and/or all of my references to obtain full information regarding my qualifications. I also consent to the collection and use of my personal information, including reference checks, in accordance with applicable privacy laws.

I understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is "at will," meaning that I may resign at any time, and the employer may terminate my employment at any time, with or without cause. I also understand that this "at-will" relationship may not be changed except by a written agreement signed by an authorized representative of the organization. This "at-will" employment relationship is subject to all relevant local, state, and federal laws.

In the event of employment, I understand that any false or misleading information provided in my application or interview may result in termination. I further agree to abide by all company rules and policies.
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Equal Employment Opportunity Statement

At Sacred Heart Care Center, we are proud to be an Equal Opportunity Employer. We are committed to fostering a diverse and inclusive workplace within our nursing home and assisted living community. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, age, national origin, disability, genetic information, veteran status, or any other protected characteristic under applicable law. We are dedicated to creating a respectful, safe, and supportive environment for both our residents and staff.
Voluntary Self-Identification (Confidential)

As an equal opportunity employer, we are committed to creating an inclusive environment and fulfilling our obligations under federal affirmative action regulations. To help us meet these goals, we invite you to voluntarily self-identify your demographic information. This data is kept confidential and used only for compliance and reporting purposes.
Gender:

MaleFemaleNon-binary/Third genderPrefer not to say
Race/Ethnicity:

Hispanic or LatinoWhite (Not Hispanic or Latino)Black or African AmericanAsianNative Hawaiian or Other Pacific IslanderAmerican Indian or Alaska NativeTwo or More RacesPrefer not to say
Veteran Status

I am a protected veteranI am not a protected veteranPrefer not to say
Disability Status:

Yes, I have a disability (or previously had one)No, I do not have a disabilityPrefer not to say
Submission of this information is voluntary and refusal to provide it will not affect your application.
Should be Empty:

Sacred Heart Care Center Application Form

Employment Experience

Education

References

Voluntary Self-Identification (Confidential)