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Employment Application

Position(s) applying for: *

Full time Dietary Aide - 6am - 2pm Full time RN or LPN - 6pm - 6am Full time CNA/CMA - 2pm - 10pm Full time CNA/CMA - 6pm - 6am

Date available to work: *

Expected Salary *

Name *

First

Last

Address *

City *

Zip Code *

Email *

Contact Number *

In case of Emergency Contact *

Phone *

Professional License Type *

License Number *

Are you at least 16 years of age *

Are you at least 18 years of age *

Have you ever worked by the Friendship Home before *

Dates *

Have you ever worked for a temp agency before *

Do you have a record of founded abuse or have you ever been convicted of a crime in this or any other state: If Yes, Please explain *

High School *

Years completed *

Did you graduate? *

College *

Years completed *

Did you graduate? *

Degree *

List anyone you know that works at the Friendship Home *

Employment Experience

Most Recent or Current

Employer *

Job Title *

Contact's Name *

Telephone Number *

Address (Street address, City, ST, Zip) *

Dates of Employment *

Final Rate of Pay *

Work performed *

Reason for leaving *

Next Recent

Employer *

Job Title *

Contact's Name *

Telephone Number *

Address (Street address, City, ST, Zip) *

Dates of Employment *

Final Rate of Pay *

Work performed *

Reason for leaving *

Next Recent

Employer *

Job Title *

Contact's Name *

Telephone Number *

Address (Street Address, City, ST, Zip) *

Dates of Employment *

Final Rate of Pay *

Worked performed *

Reason for leaving *

Any additional information you feel may be helpful to us in considering your application *

Applicant’s Statement

I certify that the answers given in this application are true and complete to the best of my knowledge. The facility may investigate all statements made in this application, including any criminal or abuse record. I understand that any false or misleading information provided can result in a decision not to hire, immediate discharge if hired, and civil or criminal penalties in appropriate areas.

In signing this application I understand that I will be required to fulfill all aspects of any job if I am hired to perform the job. I understand that failure to fulfill any aspect of the job may be grounds for termination. I also understand that I will be required to submit to a physical examination conducted by the Friendship Home after I am given a qualified offer of employment.

I understand that this application is not a contract of employment, that if hired, regardless of any oral representations to the contrary:
1) the employment relationship between myself and the facility is terminable at will
2) I have the right to terminate my employment at any time for any reason, and
3) The facility retains the same right. Any changes to this employment relationship must be in writing. I understand that if hired I am required to abide by all rules and regulations of the facility. I understand that, if hired, I will be required to submit documents sufficient to establish employment authorization and identity compliant with the Immigration Reform Act of 1986.

Release of Information (A photocopy of this Authorization is deemed as effective as the originaI)
I, applicant, hereby request and authorize the release of information regarding my work history to the Friendship Home Association. It is expressly understood that this information is to be used solely for the purpose of determining my eligibility for employment.

In consideration of your honoring my request, I agree to release you and your company and it’s employees from, and hold it harmless against, any and all claims of whatever nature that I might have now or in the future as a result of providing such information.

Please check box indicating you have read and agree to the information above. *

Applicant's Statement Release of Information

By checking this box and typing my name below, I am electronically signing my application. *

Signature Box

Name *

First

Last

Upload Resume if desired *

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