Triple Angels Assisted Living
Application For Employment
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Permanent Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
How Did You Hear About This Position?
Referred By
Are you legally entitled to work in the United States?
Yes
No
Are you at least 18 years of age?
Yes
No
In Case of Emergency Contact:
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship to You
U.S Military or Naval Services
Rank
Present Membership in National Guard or Reserve?
Yes
No
Have you ever been convicted of a crime other than a minor traffic violation?
Yes
No
If yes, please explain:
Position Desired
RN
LPN/LVN
Homemaker
Home Health Aid
Staff
Clerical
Personal Care Attendant
Other
Have you passed Competency Testing?
Yes
No
Do you have a certificate?
Yes
No
Do you have a driver's license?
Yes
No
Do you currently have a car or reliable transportation?
Yes
No
Do you have any professional licenses, certifications, and/or registrations?
Yes
No
Professional Licenses, Certifications, and Registrations
Please list name, type, state issued, date of expiration, current status
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References
Please list three references. Include Name, Address, Company/Position, Phone Number
Please list education. Include Name, Location, Years Attended, Year of Graduation,Degree/ Certification
Please list former employers. Include Company Name, Position Held, Address, Salary, Date, Reason for Leaving and If We May Contact
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Voluntary Self Identification Information
Triple Angels Assisted Living is an Equal Opportunity/ Affirmative Action Employer. ides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. This data is for analysis and affirmative action only and submission of this information is voluntary. this data will be kept in a confidential file separate from your Application for Employment.
Date
-
Month
-
Day
Year
Date
Position Applied For
Gender
Female
Male
Choose Not To Respond
Race
Asian
American Indian/ Alaskan Native
Native Hawaiian/ Pacific Islander
Black/ African/ African- American
Hispanic/Latino
White/ Caucasian
Two or more races
Choose not to respond
Veteran Status
Vietnam era veteran
Disabled veteran
Other veteran
Not applicable
Choose not to respond
Disability Status
Disabled
Not Disabled
Choose not to respond
Should be Empty: