It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin, disability or other protected classifications. Please carefully read and answer all questions. You will not be considered for employment if you fail to completely answer all the questions on this application. You may attach a résumé, but all questions must be answered.

"Employer"

Position applying for

First Name

Middle Name

Last Name

Address

Street Address and/or Mailing Address

Street Address Line 2

CityState

Zip

Home Telephone Number

Business Telephone Number

Cellular Telephone Number

Date you can start work

Date

Salary Desired

Do You have a high school diploma or GED

YesNo

Hours:

Status:

RegularTemporary

Are you authorized to work in the U.S. on an unrestricted basis?

YesNo

Have you ever been convicted of a felony? (Convictions will not necessarily disqualify an applicant for employment.)

YesNo

If yes, explain

Have you been told the essential functions of the job or have you been viewed a copy of the job description listing the essential functions of the job?

YesNo

Can you perform these essential functions of the job with or without reasonable accommodation?

YesNo

School Name & Degree

Address/City/State

School Name & Degree

Address/City/State

Other

Address/City/State

SPECIAL SKILLS List any special skills or experience that you feel would help you in the position that you are applying for (leadership, organizations/teams, etc.)

References

Please list three professional references not related to you, with full name, address, phone number, and relationship. If you don't have three professional references, then list personal, unrelated references.

Name, Address/City/State, Phone #, and Relationship.

WORK HISTORY

Start with your present or most recent employment and work back. Use separate sheet if necessary. (INCLUDE PAID AND UNPAID POSITIONS)

Job Title #1

Start Date (mo/day/yr)

Date

End Date (mo/day/yr)

Date

Company Name

Supervisor's Name

Phone Number

City

State

Zip

Duties

Reason for Leaving

Starting Salary

Ending Salary

May We Contact Your Present Employer

YesNoN/A

Job Title #2

Start Date (mo/day/yr)

Date

End Date (mo/day/yr)

Date

Company Name

Supervisor's Name

Phone Number

City

State

Zip

Duties

Reason for Leaving

Starting Salary

Ending Salary

Job Title #3

Start Date (mo/day/yr)

Date

End Date (mo/day/yr)

Date

Company Name

Supervisor's Name

Phone Number

City

State

Zip

Duties

Reason for Leaving

Starting Salary

Ending Salary

I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize the Employer to make an investigation of any of the facts set forth in this application and release the Employer from any liability. The employer may contact any listed references on this application. I acknowledge and understand that the company is an "at will" employer. Therefore, any employee (regular, temporary, or other type of category employee) may resign at any time, just as the employer may terminate the employment relationship with any employee at any time, with or without cause, with or without notice to the other party.

Applicant Signature

Clear

Date

To Whom It May Concern:

I have applied to Union County Health & Rehab for employment. To enable this facility to properly evaluate my qualifications, I am requesting and authorizing you to release and furnish any and all information in your records or files or within your knowledge, concerning my present and/or past employment with you.

I authorize the investigation of all statements contained on this application and the references listed, to give any and all information concerning my previous employment and any pertinent information they may have and release all persons from liability and damages that may result from furnishing that information to you.

Applicant Signature

Clear

PRINT NAME

Social Security Number

List Any Other names used while employed?

Nursing Assistant Application

Nursing Assistant Application

Standard Application for Employment

Position Information

Qualifications

RECORD OF INFORMATION RELEASE

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