Employment Application Form

Application For Employment
It is the policy of this facility to fully comply with all Federal and State laws governing fraud and abuse in the health care programs and to expect all employees, contractors and consultants to conduct themselves in an ethical and responsible manner.

Federal and State laws prohibit discrimination in employment. Applicants are considered without regard to race, color, religion, age, sex, marital status, national origin, ancestry, physical or mental disability, sexual orientation, veteran's status, genetic predisposition or any other legally protected class.
Name:*

First NameLast Name
Birth Date*

MonthDayYear
Phone Number:*

Area CodePhone Number
E-mail Address:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How were you referred to us?*

Walk-InEmployeeNewspaper AdFacebookTwitterCraigslistOther (please specify)
Others:
Date you are available to start:*

MonthDayYear
Date
Have you ever worked at Gladeview before?*

YesNo
If yes, when?
Have you applied at Gladeview before?*

YesNo
If yes, when & what position?*
Position Desired*

Registered NurseLPNCertified Nursing AssistantPhysical TherapistOccupational TherapistPTACOTACookDietary AideTRDRecreation AssistantMaintenanceOther
Hours Desired*

Full time (32-40 hours)Part Time (Up to 24 hours)Per Diem
Shift Desired*

Days (7am-3pm)Evenings (3pm-11pm)Nights (11pm-7am)
Have you ever been convicted of a felony?*

YesNo
If yes, please explain:
Are you legally authorized to work in the United States?*

YesNo
Work History
Employer 1
Business Name*
Position*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Currently Still Employed?*

YesNo
Describe your job duties*
Reason for leaving*
May we contact this employer?*

YesNo
Salary *
per hour
Employer 2
Business Name*
Position*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Ending Salary
per hour
Currently Still Employed?*

YesNo
Describe your job duties*
Reason for leaving*
May we contact this employer?*

YesNo
Ending Salary *
per hour
Employer 3
Business Name*
Position*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Currently Still Employed?*

YesNo
Describe your job duties*
Reason for leaving*
May we contact this employer?*

YesNo
Ending Salary *
per hour
Job Skills & Training
Describe your skills:*
Training or Certifications:
Education

High School Diploma/GEDTrade School/Technical SchoolSome CollegeCertificate ProgramAssociates DegreeBachelors DegreeMaster's DegreeOther
Please complete the following:
Last Grammar or High School Attended:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Did you graduate?*

YesNo
Course of Study:*
Year Completed:*

MonthDayYear
Date
College Attended
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Did you graduate?

YesNo
Course of Study:
Minor/Major
Year Completed:

MonthDayYear
Date
If applying for a position which requires a license or certification, please indicate which type you have. Otherwise, please select N/A.

Registered NurseLicensed Practical NurseCertified Nursing AssistantPhysical TherapistOccupational TherapistOccupational Therapy AssistantPhysical Therapy AssistantTherapeutic Recreation DirectorN/AOther
State & Type of License/Certification
License/Certification Number
Has your license or certification ever been suspended?

YesNo
If yes, please explain:
References

Please list three (3) work references
Reference 1
Name:*

First NameLast Name
Position*
Business Name*
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reference 2
Name:*

First NameLast Name
Position*
Business Name*
Phone Number*

Area CodePhone Number
Years Known:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reference 3
Name:*

First NameLast Name
Position*
Business Name*
Phone Number*

Area CodePhone Number
Years Known:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload Resume:

Upload a File

Cancelof

Employment Application Disclaimer and Acknowledgement
- I understand that any employment offer will be contingent upon the facility's receipt of satisfactory references, a satisfactory physical examination, a criminal background check and fingerprint submission, and to submitting documentary proof of my identity and eligibility to work in the United States.
- I understand that if employed, I will be "an employee-at-will" which means that both the Gladeview and I can terminate my employment at any time, for any reason consistent with applicable state and federal law.
- I understand that this application is not a contract of employment.
- I understand that Gladeview may thoroughly investigate my work and personal history and verify all data given on this application, on related papers, and in interviews. I authorize all individuals, schools, and employers named therein, except my current employer so noted, to provide any information requested about me, and I release all parties involved from any and all liability arising out of the release of this information.
- I certify that I am under no contractual obligations that would proclude me from working for the facility.
- I further certify that all the statements herein are true and understand that any falsification or material omissions may result in refusal of employment, or, if hired, may result in termination of employment.
Signature

Clear
Enter the message as it's shown*
Should be Empty: