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EMPLOYMENT APPLICATION Camilla Hall Nursing Home

Camilla Hall is an equal opportunity employer and affords equal opportunity to all applicants for all positions without regard to race, color, religion, gender, national origin, age, disability, veteran status or any other status protected under local, state or federal laws.

Position(s) Applying for: *

Date of Application: *

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First Name: *

Last Name: *

Middle Name:

Address: *

City: *

State: *

Zip Code: *

Phone Number: *

Last four digits of your SSN: *

E-mail Address: *

How did you hear about us?

Are you legally eligible to work in the United States? (Proof of eligibility will be required upon offer of employment) *

Yes No

Are you over the age of 18 years? (If no, you will be required to provide authorization) *

Yes No

Can you, with or without reasonable accommodation, perform the essential functions of this job? (If you have any questions about the functions of the job, please ask before answering this question.) *

Yes No

Have you ever applied to Camilla Hall before? (If yes, please give the date.) *

Yes No

If you have applied to Camilla Hall before, please enter the date:

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Have you ever been convicted of a felony? (A conviction will not necessarily disqualify you.) *

Yes No

If you have been convicted of a felony, please explain:

Do you have a valid PA driving license? (For driving positions only.)

Yes No

Have you been convicted of any moving violations in the past five years? *

Yes No

If you have been convicted of any moving violations in the past five years, please explain:

Is anyone related to you employed at Camilla Hall? *

Yes No

If anyone related to you is currently employed at Camilla Hall, please give their name and relationship to you:

What salary or rate of pay do you expect to receive if employed? *

On what date would you be available to start work? *

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Type of employment you are applying for: *

Days & hours you are available:

Sunday

A.M. P.M.

Monday

A.M. P.M.

Tuesday

A.M. P.M.

Wednesday

A.M. P.M.

Thursday

A.M. P.M.

Friday

A.M. P.M.

Saturday

A.M. P.M.

EDUCATION

Elementary School: *

Secondary School: *

High School: *

College - Please include the name & location, your major, number of years completed, and your diploma/degree:

Graduate - Please include the name & location, your major, number of years completed, and your diploma/degree:

Vocational - Please include the name & location, your major, number of years completed, and your diploma/degree:

Please list any academic honors, scholarships, and/or offices held (Do not list any which reflect your race, color, religion, gender, national origin, age, disabilities or veteran status):

Describe any specialized training, apprenticeships, licenses or skills:

Have you received any job-related training in the United States Military? *

Yes No

If you have received any job-related training in the United States Military, please describe:

EMPLOYMENT HISTORY (Please begin with current or most recent employer)

Employer 1

Company Name: *

Employment Dates: *

Starting & Ending Salary: *

Name & Title of Supervisor:

Address:

Phone:

Description of Duties: *

Reason for Leaving: *

Employer 2

Company Name:

Employment Dates:

Starting & Ending Salary:

Name & Title of Supervisor:

Address:

Phone:

Description of Duties:

Reason for Leaving:

Employer 3

Company Name:

Employment Dates:

Starting & Ending Salary:

Name & Title of Supervisor:

Address:

Phone:

Description of Duties:

Reason for Leaving:

Employer 4

Company Name:

Employment Dates:

Starting & Ending Salary:

Name & Title of Supervisor:

Address:

Phone:

Description of Duties:

Reason for Leaving: *

REFERENCES (Please list three persons who are not related to you, or previous supervisors who can provide professional references.)

Reference 1

Name: *

Phone: *

Years Known: *

Address:

Relationship: *

Reference 2

Name: *

Phone: *

Years Known: *

Address:

Relationship: *

Reference 3

Name: *

Phone: *

Years Known: *

Address:

Relationship: *

Applicant Acknowledgement and Authorization Please Read Carefully Before Signing I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery. I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by Camilla Hall, such employment is at will, for no specified duration and may be terminated by either Camilla Hall or myself at any time, with or without cause of notice. I understand that none of the documents, policies, procedures, actions, statements of Camilla Hall or its representatives used during the employment process is deemed a contract of employment real or implied. I understand that no representative of Camilla Hall, except the Administrator, has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the Administrator of Camilla Hall. In consideration for employment with Camilla Hall, if employed, I agree to conform to the rules, regulations, policies and procedures of Camilla Hall at all times and understand that such obedience is a condition of employment. I understand that due to the nature of Camilla Hall business, attendance and punctuality are considered essential requirements of every job and that poor attendance or tardiness will result in disciplinary action. I understand that if offered a position with Camilla Hall, I may be required to submit to a pre-employment medical examination, drug screening and background check as a condition of employment. I understand that unsatisfactory results from refusal to cooperate with, or any attempt to affect the results of these pre-employment tests and checks will result in withdrawal of any employment offer or termination of employment if already employed. I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to Camilla Hall and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that this application is considered current for six months. If I wish to be considered for employment after this period, I must fill out and submit a new application. BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREED TO THE ABOVE STATEMENTS.

Applicant Signature: *

Date of Signature: *

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To attach resume, if applicable:

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Job Knowledge
Quality of Work
Attendance
Punctuality
Cooperation
Initiative
Attitude