St. Agnes Home - Application for Employment

St. Agnes Home - Application for Employment

St. Agnes Home provides equal employment opportunities (EEO) to all employees and applicants for employment regardless of race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty or status as a covered veteran in accordance with applicable federal, state and local laws. This policy applies to all terms and conditions of employment, including, but not limited to hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

The Home expressly prohibits any form of unlawful employee harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability or veteran status. Improper interference with the ability of our employees to perform their expected job duties is absolutely not tolerated

This application is active for 90 days.

Personal Information

First Name*

Last Name*

If you have used other names in the past, please list all other names you have used which the Home may need to check your previous employment, education, or licensure. Type N/A if not applicable*

Street Address*

City, State, Zip Code*

If you have lived at the above address for less than 12 months, list previous address:

Phone:*

List home (h) and cell (c) if applicable

E-Mail:*

How Did you Learn about this Exciting Opportunity?*

Why Do you Want to Work for St. Agnes Home?*

Position Desired (i.e. CNA, Dietary Aide, housekeeping, etc)*

Pay Expected:*

Status Desired*

Full-Time (40hrs/wk)Part-Time (8-36 hrs/wk)TemporaryPer Diem (PRN: As Needed)

If part-time or per diem, what days? (check all that apply)

Shift Desired (i.e. day, evening, or overnight)*

Are you available to work Overtime, if asked?

YesNo

When will you be available to begin work? (We typically conduct our orientations every other Monday and Tuesday from 9:00 AM-4:00PM)*

Are you legally eligible for employment in the United States?*

YesNo

Required Questions

Evaluate the following statements.*

Rows	Yes	No
1. Are you at least 16 years of age?
2. Have you filed an application with us before?
3. Have you been employed with us before?
4. Do you have relatives working here?
5. Are you employed now?
6. May we contact your present employer?
7. Are you on layoff and subject to recall?
8. Have you ever been involuntarily discharged from a job?
9. Are you willing to take a physical examination and/or drug test upon a conditional offer of employment?
10. Have you ever been convicted of a crime? (Misdemeanor or Felony, conviction includes guilt by trial, a plea of guilty, or a plea of Nolo Contendre)

If yes to #2 or #3 above, list Date(s):

If yes to #4: Name and Relationship:

If yes to #8: please explain and give dates:

If yes to #10: please explain and give dates, crime, location, nature of offense, disposition and punishment imposed.

Education Information

High School Name and Location*

# Years Completed; Did you graduate?*

Degree or Diploma

Business/Trade/Technical School Name and Location

Course of Study

# Years Completed; Did you graduate?

College School Name and Location

# Years Completed; Did you graduate?

Course of Study

Degree or Diploma

Graduate School Name and Location

Course of Study

# Years Completed; Did you graduate?

Degree or Diploma

Professional Licenses and/or Certification

Type, Organization or State Issued (Type N/A if not applying for a nursing position)*

Date Issued/Expiration Date (Type N/A if not applying for a nursing position)*

(Issue) MM-DD-YYYY (Expiration) MM-DD-YYYY

Number (Type N/A if not applying for a nursing position)*

Type, Organization or State Issued

Date Issued/Expiration Date

(Issue) MM-DD-YYYY (Expiration) MM-DD-YYYY

Number

Type, Organization or State Issued

Date Issued/Expiration Date

(Issue) MM-DD-YYYY (Expiration) MM-DD-YYYY

Number

Have you ever had any certificate, license, registration or other privilege to practice a health care profession denied, revoked, suspended, restricted, censured, reprimanded, or placed on probation by a state or U.S. jurisdiction, federal or foreign authority or have you ever surrendered such credential to avoid or in connection with, action by such authority?*

YesNo

If Yes to the above, please explain:

10. Can you perform the essential functions involved in the job or occupation for which you applied either with or without reasonable accommodations?*

YesNo

Employment

Please give accurate, complete Full-Time and Part-Time employment record. Start with your present or most recent employer. Explain any gaps in employment history:

EMPLOYER (1) Most Recent*

Phone: (include area code)*

Address:

Include Street, City, State and Zip

When were you employed there? Reason for Leaving:*

(Month & Year) From: ___________ To: ____________

Hourly Rate/Salary:*

Start: ___________ Last: ____________

Name of Supervisor:*

Job Title/Work Description:*

EMPLOYER (2) Please complete if employed less than 2 years at your last employer

Phone: (include area code)

Address:

Include Street, City, State and Zip

When were you employed there? Reason for Leaving:

(Month & Year) From: ___________ To: ____________

Hourly Rate/Salary:

Start: ___________ Last: ____________

Name of Supervisor:

Job Title/Work Description:

EMPLOYER (3)

Phone: (include area code)

Address:

Include Street, City, State and Zip

When were you employed there? Reason for Leaving:

(Month & Year) From: ___________ To: ____________

Hourly Rate/Salary:

Start: ___________ Last: ____________

Name of Supervisor:

Job Title/Work Description:

Military Information

Are you a Veteran?

YesNo

Duty or Specialized Training

Other

State any other additional information, such as volunteer work of other skill or experience, which you believe may be beneficial to us in considering your application:

Resume Upload

Upload a copy of your resume here (optional)

Upload a File

Acknowledgment and Authorization

I understand and agree that, if hired, my employment is for no definite period and can be terminated at any time with or without notice, with or without cause by either myself or St. Agnes Home. In the event that I am employed, I understand that regardless of the shift and job that I am first employed, I may be required to accept a change of job or shift depending on my demonstrated skills after employment and the needs of the Home. I understand that I must meet the standards established by the Home for my job classification as a condition of initial and continued employment, which may be determined by a physical examination and/or drug test. I understand also, that if employed, I am required to abide by all rules and regulations of the Home. I understand that no supervisor, officer, agent, or representative of the Home, other than its Administrator, has any authority to enter into any agreement for employment for any period of time, or to make any agreement contrary to the foregoing.

In addition, I understand and agree that this application shall be valid for a period of ninety (90) days. If I wish to be considered after ninety (90) days, I recognize that I must complete a new application for employment.

I grant permission to the Home to investigate my personal, educational, and work histories thoroughly. In addition, I authorize the Home to confirm all information that I have given in connection with my application for employment and to obtain information and/or a report from any state agency or any other entity which may include both or general and personal information about me. I, furthermore, release the Home and its agents from liability for any acts or omissions occurring during either such investigation or confirmation, or both. I further release any one or more of individuals, organizations and their agents, educational institutions that I attended and their agents, or my former employers and their agents from any liability for any acts or omissions occurring in its or their responses to the Home’s inquiries about me. This release specifically covers the employers and their agents and the educational institutions and their agents that I have identified in my responses to the inquiries made on this application form. I understand and agree that the Home may deny my application for employment or if it has already employed me that the Home may terminate my employment because of information obtained during the Home’s investigation or confirmation, or both, of my responses made on my employment application. Upon the termination of my employment with the Home regardless of when, how, or why my employment ends, and regardless of whether the Home or I terminate my employment. I authorize the Home to release information about my employment history with the Home and release the Home and all of its agents from any liability for the disclosure of information about my employment history to either governmental agencies or employers to whom I have applied for a job.

CERTIFICATION AND AUTHORIZATION
I certify that I have given true and complete information in response to each category of information requested. I have also read, understood, and accepted the conditions of employment stated in this application. I further authorize the release of information as stated above. I recognize St. Agnes Home’s right either to revoke any employment offer or to terminate my employment if it ever finds any of my responses written on this application either to falsify or to omit, or both, any information.

By entering your name below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By signing your name below, you consent to be legally bound by this Agreement's terms and conditions and you are verifying the information is accurate.

Electronic Signature (your name)*

Date*

MonthDayYear

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