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Employment Desired:
Position Applying For
*
Caregiver/CNA
Kitchen Staff
Activities Assistant
Activities Director
Excercise Coordinator
Social Services
Housekeeping
Maintenance
Nursing
Administration
Date You Can Start
*
-
Month
-
Day
Year
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Salary Desired
Have You Worked Here Before?
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Yes
No
What type of position are you looking for?
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Full-time
Part-time
Temporary
Other
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Education:
High School
Name of High School Attended
Number of Years Attended
Graduated?
Yes
College
Name of College/University Attended
Number of Years Attended
Graduated?
Yes
Area of Study/Degree
Graduate School
Name of Graduate School Attended
Number of Years Attended
Graduated?
Yes
Area of Study/Degree
Trade School/Other
Name of Trade/Technical/Other School Attended
Number of Years Attended
Graduated?
Yes
Option 2
Area of Study/Degree
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Skills/Qualifications:
Skills
*
List any relevant skills
Qualifications
*
List any relevant certifications or qualifications
Current Employment:
Current Employer
Name of Current Employer or NONE if not Employed
Position
Reason for Leaving?
Start Date
-
Month
-
Day
Year
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May We Contact?
Yes
No
Previous Employment:
Previous Employer
Name of Previous Employer
Position
Reason for Leaving?
Start Date
-
Month
-
Day
Year
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End Date
-
Month
-
Day
Year
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Previous Employer
Name of Previous Employer
Position
Reason for Leaving?
Start Date
-
Month
-
Day
Year
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End Date
-
Month
-
Day
Year
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References:
Reference 1
*
Name of Reference
Relationship
*
Years Acquainted
Phone
*
Email
Reference 2
*
Name of Reference
Relationship
*
Years Acquainted
Phone
*
Email
Availability/Preference
Prefered Shift
*
Morning (6:45-15:00)
Swing (15:00-23:00)
Noc (23:00-6:45)
Prefered Days
*
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Available to work Holidays?
*
Please Select
YES
NO
On Call and/or Rotating Shifts?
*
Yes
No
Other
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Questionaire
If you were just starting your current/last job, what would you do differently?
*
List any relevant skills
What qualifications do you have for the position you are applying for?
*
List any relevant skills
How would your most recent surpervisor describe your personal work style? How do you ensure that all of your tasks have been completed?
*
List any relevant skills
What are your strong points?
*
List any relevant skills
What are your weak points?
*
List any relevant skills
Why did you leave your last job? Or, why do you plan on leaving?
*
List any relevant skills
Besides helping others, what interests you about this line of work?
*
List any relevant skills
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How do you cope with stress?
*
List any relevant skills
Describe your understanding of professional boundaries and why you think they are important?
*
List any relevant skills
What actions do you take when there is a coworker conflict?
*
List any relevant skills
What is your greatest personal accomplishment/s?
*
List any relevant skills
Please select two of the following options that you consider to be your strengths.
*
Competency
Character
Chemistry
Have you ever been accused or found guilty of committing abuse? If yes, please explain...
*
Yes
No
Other
Would you have any problems passing a background check?
*
Yes
No
Other
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Release of Information
Name
*
First Name
Last Name
Date
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