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Employment Application Form

Applicant Data

Last Name:

First Name:

Middle Name:

Date of Birth: (if under 18)

Street Address:

City:

State:

Zip Code:

Telephone Number:

Social Security Number:

Are you authorized to work in the U.S.?

Category of work:

Date Available:

Days you can work:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

What hours can you work:

Have you ever applied with us before?

If yes, when:

Have you ever worked for us before?

If yes, when:

Education

Select Grade Completed:

Last High School Attended:

Major Course of Study:

College, Technical, Trade or Other:

Name of School:

Major Course of Study:

Degree or Diploma Granted:

If you are an RN, LPN, CNA, CHNA or PCA

Please check areas in which you have experience or interest:

Hospitality:

Nursing Home:

Home Health:

Charge:

Administration:

Adult Care Facility:

Professional Licensure/Registration Data

License Number:

Expiration Date:

Skills

Pleae check areas in which you have had experience or training:

Data Processing:

Typewriter:

Switchboard:

Medical terminology:

Other:

If other:

Work History

Please provide the names of your most recent employers complete with the company names, addresses, dates of employment, positions or duties

Personal References

Please provide names, addresses and phone numbers:

Excluding traffic violations, have you ever been convicted of a crime?

If yes, describe in full:

Do you accept the possibility of working weekends, holidays, or rotation shifts:

Do you understand that, due to the nature of the services we provide, an exceptional record of attendence, promptness and dependability is required of all employees:

Do you understand that employment is contigent upon satisfactory education, prior employments and reference verification:

Do you further understand that willfully making flase statements on this application will be sufficient cause for discharge:

Do you understand that we are an Equal Opportunity Employer as outlined in federal and New York State laws against discrimination? Also, that no qualified person with a disability shall be subjected to discrimination in our employment process:

Do you understand that any offer of employment is contingent upon your providing proof of U.S. Citizenship or authorization to work in the U.S.:

We are committed to providing "loving care" to all clients and we require that all employees share this commitment. if employed by us, can you share in this commitment:

We are an Equal Opportunity Employer

I understand that all information concerning residents, clients, their doctors, and fellow employees is strictly confidential. I agree to honor the policy which states certain corporate and employee business is confidential. i hearby affirm the information provided in this application to be true and complete to the best of my knowledge.

Online Application

Employment Application Form