| APPLICANT DATA |
| 1. Last Name |
| 2. First Name |
| 3. Middle Name |
| 4. Date of Birth (if under 18) |
| 5. Street Address |
| 6. City |
| 7. State |
| 8. Zip Code |
| 9. Phone |
| 10. Social Security Number |
| 11. Are you Authorized to work in the US? Yes No |
| 12. Category of Work Full Time Part Time Temporary |
| 13. Date Available |
| 14. What days can you work? M T W TH F SA SU |
| 15. What hours can you work? |
| 16. Have you ever applied with us before? No Yes - When? |
| 17. Have you ever worked for us before? No Yes - When? |
| EDUCATION |
| 18. Check Grade Completed 7th 8th 9th 10th 11th 12th |
| 19. Last High School Attended |
| 20. Major Course of Study |
| 21. College, Technical, Trade or Other |
| 22. Name of School |
| 23. Major Course of Study |
| 24. Degree or Diploma Granted |
| If you are an RN, LPN, CNA, CHNA or PCA |
25. Please check areas in which you have experience or interest:
Hospital Nursing Home Home Health Charge Administration Adult Care Facility |
| Professional Licensure/Registration Data |
| 26. License Number |
| 27. Expiration Date |
| SKILLS |
28. Please check areas in which you have had experience or training:
Data Processing Typewriter Switchboard Medical Terminology
Other |
| WORK HISTORY |
29. Please provide the names of your most recent employers complete with Company Names and Addresses, Dates of Employment and Positions or Duties.
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| PERSONAL REFERENCES |
30. Please provide Names, Addresses and Phone Numbers.
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| 31. Excluding traffic violations, have ever been convicted of a crime? Yes No |
32. If yes, describe in full...
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| 33. Do you accept the possibility of working weekends, holidays, or rotation shifts? Yes No |
| 34. Do you understand that, due to the nature of the services we provide, an exceptional record of attendance, promptness and dependability is required of all employees? Yes No |
| 35. Do you understand that employment is contingent upon satisfactory education, prior employments and reference verification? Yes No |
| 36. Do you further understand that willfully making false statements on this aplication will be sufficient cause for discharge? Yes No |
| 37. Do you understand that we are an Equal Opportunity Employer as outline in federal and New York State laws against discrimination? Also, that no qualified person with a disability shall be sujected to discrimination in our employment process? Yes No |
| 38. 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.? Yes No |
| 39. 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 this commitment? Yes No |
| 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 hereby affirm the information provided in this application to be true and complete to the best of my knowledge.
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