CNA Online Application
Your Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best time we can reach you via phone?
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Referral Source
Advertisement
Employee
Government Agency
Walk-In
Private Employment Agency
Other
Name of Publication/Reference Source (if applicable):
Have you ever been employed by Groton Community Health Care Center?
*
Yes
No
Have you ever interviewed for a position with Groton Community Health Care Center?
*
Yes
No
Can you work:
*
Full-Time
Part-Time
Per Diem
Temporary
Which shift(s) can you work?
*
Days
Evenings
Nights
Rotation
Are you under 18 years of age?
*
Yes
No
Are you legally authorized to work in the United States?
*
Yes
No
Have you ever been convicted of a misdemeanor or felony? *Conviction will not necessarily result in disqualification for employment.*
*
Yes
No
Date you wish to begin employment
*
-
Month
-
Day
Year
Date
Type of License or Registry
*
License or Registry Number
*
Type of License or Registry (if applicable)
License or Registry Number (if applicable)
Salary Expectations
Attach Your Resume
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Attach Copies Of Your Nursing Credentials
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Applicant's Agreement and Certification
"I certify that the information given by me in this application is true in all respects; and I agree that, if employed by Groton Community Health Care Center and any information is found to be false in any way, I may be subjected to dismissal without notice, if and when discovered. I agree, if employed, to work faithfully and diligently, to be careful and avoid accidents, to come to work promptly, and to maintain Resident/Consumer confidentiality. Should I accept an offer of employment, I agree to be employed for an introductory period and understand that I may be dismissed at anytime during this introductory period at the discretion of my employer. If employed, I agree to abide by all present and subsequently-issued center and personnel policies and rules. However, I also understand that after completion of the introductory period, my employment is for no set period of time and may be terminated by either party at any time."
Authorization for Release of Information
I hereby authorize Groton Community Health Care Center to request from former employers an evaluation of my job performance and dates of association and to contact my references and confirm all professional achievements stated within my application for employment. I release all persons involved from any and all claims of whatever nature I might have as a result of any and all responses given to Groton Community Health Care Center. Further, I understand all responses are the confidential property of Groton Community Health Care Center. If you are hired, a post-offer medical examination will be required before you start work. If the examination discloses medical conditions that prevent you from successfully performing the essential functions of the job, Groton Community Health Care Center will attempt to make accommodations to allow you to work. If no reasonable accommodations can be found, or they cause an undue hardship on Groton Community Health Care Center, the tentative offer of employment will be withdrawn. It is the policy of Groton Community Health Care Center not to refuse employment to a qualified individual with a disability because of his/her need for an accommodation that would be required by the ADA.
Equal Opportunity Employer Statement
Groton Community Health Care Center is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.
Applicant's Signature
*
Email List to Reply-All
Print
Save and Continue Later
Submit
Should be Empty: