Harbert Hills Nursing Home - Employment Application FormEMP - Job Application Personal Information Name * Middle Name Last Name * Email * Social Security # Date of Birth * Home Phone Mobile Phone Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/PostalEmployment InformationPosition for which you are applying. RN LPN CNA Cook Laundry Housekeeping Certified Activity DirectorShift you can work: Day Evening NightEmployment Desired Full-time Part-time Full-time or Part-time TemporaryAre you employed at the present time. If yes, please complete the information below. Yes No Employer's Name: Employer's Address: May we contact your present employer at this time? Yes No 1 - How long have you been employed with this employer? 2 - If offered a position, when can you report to work? 3 - If hired, can you show proof of your legal right to work in the U.S.? Yes No4 - Have you ever been dismissed, or asked to resign from any position? Yes No5 - Have you ever been convicted of a felony or misdemeanor? Yes No6 - Have you ever been involved in any liability suit against anyone? Yes No If you answered yes ot number 4, 5, or 6, please explain: EducationSelect highest High School grade completed. 9th 10th 11th 12thSelect highest College completed. 1 Year 2 Year 3 Year 4 Year Name and location of last school attended: Employment Experience (List the most recent first) Dates (Start-End) Name & Address Position(s) Held Dates (Start-End) Name & Address Position(s) Held Dates (Start-End) Name & Address Position(s) Held Dates (Start-End) Name & Address Position(s) Held References - List 6 individuals whom you know well, previous employers or coworkers. Do not include relatives. Name &Address (Include City, State, &Zip) Phone Relationship Name &Address (Include City, State, &Zip) Phone Relationship Name &Address (Include City, State, &Zip) Phone Relationship Name &Address (Include City, State, &Zip) Phone Relationship Name &Address (Include City, State, &Zip) Phone Relationship Name &Address (Include City, State, &Zip) Phone Relationship Employment Understanding (Please read and sign)This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to the ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate ni such investigation and release from al liability or responsibility al persons, companies, or corporations supplying such information. I consent to take the physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential duties I would be required to perform.I further understand that my employment will be subject to random drug testing at any such time deemed necessary by the institution and will be contingent on the fact of passing said drug test. I also understand that my employment could be terminated for any misstatement or omission of fact appearing on this application form.If employed, I will be required to complete an Employment Verification Form (1-9), and within three days show satisfactory evidence of identity and eligibility for employment. Signature signature keyboard Clear Date Submit If you are human, leave this field blank.
