Date of Application

Equal opportunity is given to all applicants regardless of race, color, age, sex, religion, national origin, disability, pregnancy, genetic information, and military or veteran status.

This application shall become void after 30 days but can be reactivated for an additional 30 days by written request of the applicant.

First Name *

Last Name *

Address (Street, City, Zipcode) *

Email *

Phone *

Salary Required *

Date available to start work if a position is offered *

Are you at least 18 years of age? *

Have you ever applied for work here before? *

If you have applied here before, when?

Have you ever worked here before? *

If you have worked here before, when?

Are you either a U.S. citizen or an alien who has the legal right to work in the U.S.? *

Have you ever been convicted of a crime or pled guilty or nolo contendere to a charge involving moral turpitude, abuse, assault, battery, arson, larceny, robbery, burglary, sex offenses (including gratification of lust), identity theft, possession or sale of drugs, murder, manslaughter, or any other crime involving a vulnerable adult or child? *

If you have been convicted, explain?

Are you able to perform the essential functions of the position(s) for which you are applying with or without a reasonable accommodation? *

Do you have a reliable means of transportation to work? *

Do you have personal or other obligations that would cause you to miss work? *

If you have obligations, explain?

If hired, will you be engaged in any other work, business, or school? *

If yes, explain?

How did you find out about this position? *

Name of person that referred you?

Do you have relatives working for our facility? *

If yes, provide name(s)

Schedules you can work? (Check all that apply) *

Employment Status Desired? *

Full Time
PRN

How often are you willing to travel? *

THIS IS FOR NURSES ONLY. License and Registration Information for Nurses and Professional Individuals( State, License Number, Expiration Date, Type) *

Educational Information - Include Military Education and Training (Education (High School, College, Graduate School, Special Training), Name and Address of School, Years Completed, Graduated (Yes or No), Degree/Major) *

Employment History - Account for all employment; Starting with the most recent job. (Company Name & Address, Years Employed, Final Position, Supervisor's Name and Contact Number, Duties, Salary, and Reason for Leaving)

Have you ever had or do you currently have a restricted license? *

If you have had or have a restricted license, explain?

Military Service?

Branch

Number of years served

Rank Achieved

Duties

Were you honorably discharged?

If no, explain?

May we contact your current employer? *

If offered a position, the Immigration Reform and Control Act of 1986 requires you to furnish proof of your employment authorization and your identity before you begin work.

If offered a position, a background check, including a criminal record check, will be conducted.

In connection with your employment or application for employment with Healthcare Facility, a consumer report may be obtained. A consumer report includes any written, oral, or other communication of any information by a consumer reporting agency bearing on a consumer's credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. *

I Accept - By selecting "I Accept" I am signing this Agreement electronically hereby authorizing healthcare facility, and any of its agents, to obtain a consumer report on me. I agree that my electronic signature is the legal equivalent of my manual signature on this Agreement.

Authorization to release employment and education records. *

I hereby authorize Healthcare Facility, or its agents, to obtain all records and/or information relating to my education and employment history. I hereby authorize all persons, entities or agencies possessing records and/or information relating in any way to my education and employment history to release all such information to Healthcare Facility's Human Resources Department.

Employment and Education records liability release. *

I hereby release Healthcare Facility, and its agents, from any and all liability related in any way to its request or receipt of the information authorized herein, and I do also hereby release any and all persons, entities or agencies possessing records and/or information relating in any way to my education and employment history from any and all liability related in any way to the release of information in accordance with this Authorization.

By selecting "I Accept" I am signing this Agreement electronically agreeing to the "Authorization to release employment and education records" and "Employment and Education records liability release" above. I agree that my electronic signature is the legal equivalent of my manual signature on this Agreement. *

I Accept

READ CAREFULLY *

I certify that the answers given by me to the foregoing questions and statements are true and complete to the best of my knowledge, and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I acknowledge that misrepresentation or omission of facts called for in this application is cause for my not being hired or my termination at any time without prior notice on me.

II *

I authorize Healthcare Facility to release to other prospective employers or information service bureaus, any information regarding my employment with Healthcare Facility or the information set forth in this application or gained by Healthcare Facility from any other companies, agencies, schools, or persons named in this application, including information regarding my employment, character, qualifications and other information they may have regarding me, whether or not it is in their records. I hereby release Healthcare Facility from all liability for any damage caused by issuing this information to outside individuals.

III *

If employed, I agree as a condition of continued employment to acquaint myself with, and to abide by all Rules, Regulations and Policies as established or amended by Healthcare Facility. However, I understand that any employment is at-will which means that my employment and compensation can be terminated with or without notice at any time, and for any reason other than an illegal reason, at the option of Healthcare Facility or myself. Nothing in this Application of Employment or the regulations and policies of the Healthcare Facility should be construed to constitute a contract of employment between Healthcare Facility and the applicant. I understand that no Healthcare Facility representative, other than the Administrator, in writing, has any authority to enter into an agreement for employment for an specified period of time, or to make any agreement contrary to this policy. I understand that my terms and conditions of employment may be changed at any time with or without notice to me.

IV *

If I am employed, I further understand and agree that when my employment is terminated for any reason, I must return all of the Healthcare Facility's property in my custody, including, but not limited to, any documents, Healthcare Facility equipment, office keys, manuals, identification cards and name badges before I am entitled to final payment of any amounts due me on separation. I also understand that the value of these items, if not returned, along with any monies I might owe Healthcare Facility, may be deducted from my final paycheck; to the extent as allowed by law.

By selecting "I Accept" I am signing this Agreement electronically agreeing to the above four statements. I agree that my electronic signature is the legal equivalent of my manual signature on this Agreement. *

I Accept

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