Application for Employment

Our Mission is to provide for the physical, social, and spiritual needs of the individual we serve, in a Christian environment. Our Values include: Responsibility, Compassion, Respect, Integrity, and Commitment.

It is the policy of our company not to discriminate due to race, color, creed, national origin, sex, sexual preference, age, marital status, religion, citizenship, disability or any other status protected by law.

Personal Info

* First Name
* Last Name
Middle Initial
* Primary Telephone Number
Email
* Address
* City
* State
* Zip Code

Detailed Personal Information

* Application Date
Secondary Telephone Number
How did you hear about us?
If referred, name of Employee:
* Position You Are Applying For:
* Date Available to Work
Salary Requirement
* Work Availability:
Full-TimePart-TimePer Diem
* Shift Desired:
DayEven.Nights
* Have you been previously employed by any of the facilities within our organization?
Have you ever worked for any of our facilities under a different name?
If Yes, what name?
* Are you legally eligible to work in the United States?
* Are you at least 18 years of age?
If not 18, do you have working papers?
* Have you ever been convicted of a crime?*
If Yes, provide details:
* Are you able to perform the essential functions of the position for which you are applying with or without reasonable accommodation?
If not, what accommodation could be made to enable you to perform in this position?
Please complete this section only if this position requires the use of a company car or driving a vehicle for company business.
Operator's License Number
License State
Please list any moving motor vehicle violations incurred within the last 3 years
* Note: Criminal background checks are conducted on all applicants. A conviction record will not necessarily be a bar to employment. Factors such as age and date of the offense, nature and seriousness of the violation or offense, and rehabilitation will be taken into account.

Educational History - High School or Below

Name and Location of High School
Choose Highest Grade Completed:
91011
12GED  

Educational History - College

Name and Location of College/High School
If degree is in progress, number of credits completed:`
If completed, what degree was granted and Major Course of Study

Educational History - College

Name and Location of College/High School
If degree is in progress, number of credits completed:`
If completed, what degree was granted and Major Course of Study

Educational History - College

Name and Location of College/High School
If degree is in progress, number of credits completed:`
If completed, what degree was granted and Major Course of Study

Other Relevant Information

Professional Designations (Name of Program (s) / Designations(s))
Have you received any additional training relevant to the position applying for?
Remarks/Skills: List any additional skills - keyboarding (WPM), computer equipment used, software, languages, etc

Military Service Record

Were you in the U.S. armed forces?
Did you receive any training that might be relevant to the position for which you are applying?
If Yes, provide details:

Employment History

Company Name
From:
To:
Address
City
State
Zip Code
Telephone Number and Extension
Last Position Held
Starting Annual Base Salary
Final Annual Base Salary
Supervisor's Name
Duties Performed
Reason for Leaving
* May We Contact This Employer?

Employment History

Company Name
From:
To:
Address
City
State
Zip Code
Telephone Number and Extension
Last Position Held
Starting Annual Base Salary
Final Annual Base Salary
Supervisor's Name
Duties Performed
Reason for Leaving
* May We Contact This Employer?

Employment History

Company Name
From:
To:
Address
City
State
Zip Code
Telephone Number and Extension
Last Position Held
Starting Annual Base Salary
Final Annual Base Salary
Supervisor's Name
Duties Performed
Reason for Leaving
* May We Contact This Employer?

References

* Name
* Address/City/State/Zip
* Telephone
* Relationship
* Years Known

References

* Name
* Address/City/State/Zip
* Telephone
* Relationship
* Years Known

References

* Name
* Address/City/State/Zip
* Telephone
* Relationship
* Years Known

Health Care Employers

List ALL health care employers that you have worked for over the past ten years:

Other State Certifications

* Are you currently registered, licensed, or certified by any state?
State Issued
Type
Number
Exp. Date
State Issued
Type
Number
Exp. Date
State Issued
Type
Number
Exp. Date

Disclaimer

I certify that the information provided in this application is true, correct, and complete to the best of my knowledge. I understand that any misstatements or omission of information on this application would be sufficient cause for and may result in the rejection of this application or dismissal from employment. I understand that neither this application nor an offer of employment creates a contract of employment between me and the facility. I further understand that my employment can be terminated at any time for any reason with or without cause by me or the facility. I understand I will be required to complete a 90 introductory period. I know that the facility will investigate my statements and agree that it may obtain any additional information it considers useful in deciding whether to employ me. I have read and understand the company's mission and values.
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