Wauneta Care and Therapy Center Employment Application

First & Last Name

M.I.

Street Address

City, State, Zip

Phone

E-mail Address

example@example.com

Date Available

Date

Social Security No.

Desired Salary

Position Applied for

Are you a citizen of the United States?

YESNOIf no, are you authorized to work in the U.S.? YES

Have you ever worked for this company?

YESNO

If so, when?

Have you ever been convicted of a felony?

YESNO

If yes, explain

High School

Address

From - To

To

Did you graduate? YESNO

College

Address

From - To

To

Did you graduate? YESNO

Degree

Other

Address

From - To

To

Did you graduate? YESNO

Degree

Please list three professional references.

Full Name

Relationship

Company

Phone

Full Name

Relationship

Company

Phone

Full Name

Relationship

Company

Phone

PREVIOUS EMPLOYMENT

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From - To

Reason for Leaving

May we contact your previous supervisor for a reference?

YESNO

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From - To

Reason for Leaving

May we contact your previous supervisor for a reference?

YESNO

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From - To

Reason for Leaving

May we contact your previous supervisor for a reference?

YESNO

Have you served in the military? If so, which branch?

Are you registered in Nebraska?

YesNo

License #:

If not Nebraska registered, have you applied for reciprocity?

YesNo

If other than honorable, explain

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

DISCLAIMER AND SIGNATURE

I CERTIFY AND AGREE AS FOLLOWS:

That this application will remain active for 30 days. If I would like to be considered for employment after 30 days, I will need to complete a new application. That evidence of false statements or incomplete information on this application will be considered sufficient cause for immediate discharge if already employed. That nothing contained in this application or in the interview process is intended to create an employment contract between Wauneta Care & Therapy Center and myself. I understand that I have the right to terminate my employment at any time with or without notice or reason and that Wauneta Care & Therapy Center retains a similar right. If selected, I will obtain an employment physical or screening, performed by a qualified staff member of Wauneta Care & Therapy Center or paid for by Wauneta Care & Therapy Center. If a screening is done at Wauneta Care & Therapy Center and the qualified staff member feels it is necessary for me to see a physician for further testing, Wauneta Care & Therapy Center will pay for that visit and the physician must certify that I am able to work before I actually begin my employment. If my job requires certification and/or education requirement, I am willing to complete the course and testing in a timely manner. I understand that Wauneta Care & Therapy Center is an Equal Opportunity Employer. All qualified persons are welcome to submit applications for employment. Applicants will be selected solely on qualification, without regard to race, color, creed, national origin, sex, pregnancy, genetics, disability, age, religion, marital status, or ancestry.

SIGNATURE:

DATE:

Date

REFERENCE CHECK

I consent to having Wauneta Care & Therapy Center contact anyone that it deems appropriate to investigate or verify any information I have given or to discuss my background, past performance, or suitability for employment. I further consent to being discussed by any person so contacted and I wave all rights to bring any action for defamation, invasion of privacy, or any similar cause against anyone contacted as a result of what he or she may say about me. I also Understand that Wauneta Care & Therapy Center will check to determine if there is a history of past abuse of any residents.

I authorize Wauneta Care & Therapy Center to release specific employment information to places where I have filed an employment application, whether during or after my employment with Wauneta Care & Therapy Center.

SIGNATURE:

DATE:

Date

PLEASE READ AND SIGN BELOW: