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Full Name
*
First
Address
*
Address*
City*
State
Zip*
Phone Day
*
Phone Evening
Email Address
*
What license do you currently hold?
CNA
RN
LPN
None
Are you over 18?
Yes
No
Do you have a Driver's License?
Yes
No
Do you own a car?
Yes
No
What shifts would you prefer?
Days
Nights
PM
Any
In an emergency notify:
Name
emergency Name
Relationship
First
Home Phone
Cell Phone
Work Phone
In an emergency notify (Secondary Person):
Name
First
Relationship
First
Home Phone
Cell Phone
Work Phone
Military Record
Were you in the Military Service of the United States?
Yes
No
Employment Desired
Position applied for
Other
If hired, on what date can you start work?
Date Format: MM slash DD slash YYYY
Salary/Rate Desired
What qualifications do you posses for this job?
Have you applied for employment with us before?
Yes
No
Have you ever been employed by us?
Yes
No
Do you object to night work?
Yes
No
Do you object to work weekends?
Yes
No
Are you able to work more than 40 hours a week?
Yes
No
Educational Background
High School
School Name and Location
Dates Attended
Date Format: MM slash DD slash YYYY
Did you Graduate?
Yes
No
Graduation Date
Date Format: MM slash DD slash YYYY
Business / Trade School
School Name and Location
Dates Attended
Date Format: MM slash DD slash YYYY
Did you Graduate?
Yes
No
Graduation Date
Date Format: MM slash DD slash YYYY
College
School Name and Location
Dates Attended
Date Format: MM slash DD slash YYYY
Did you Graduate?
Yes
No
Graduation Date
Date Format: MM slash DD slash YYYY
Employment History
Date From
Date Format: MM slash DD slash YYYY
Date To
Date Format: MM slash DD slash YYYY
Company Name
First
Company Address
Phone Number
Job Title, Duties & Shift
Supervisor Name
Most Recent Salary
Reason For Leaving
Date From
Date Format: MM slash DD slash YYYY
Date To
Date Format: MM slash DD slash YYYY
Company Name
First
Company Address
Phone Number
Job Title, Duties & Shift
Supervisor Name
First
Most Recent Salary
First
Reason For Leaving
Date From
Date Format: MM slash DD slash YYYY
Date To
Date Format: MM slash DD slash YYYY
Company Name
First
Company Address
Phone Number
Job Title, Duties & Shift
Supervisor Name
First
Most Recent Salary
Reason For Leaving
Date From
Date Format: MM slash DD slash YYYY
Date To
Date Format: MM slash DD slash YYYY
Company Name
First
Company Address
Phone Number
Job Title, Duties & Shift
Supervisor Name
First
Most Recent Salary
Reason For Leaving
If there have been any gaps in your employment during the last five years, please provide details here:
References Please list the persons who are not relatives whom we may contact as a reference.
Name
First
Relationship
Number of years known
Phone
Name
First
Relationship
Number of years known
Phone
Name
First
Relationship
Number of years known
Phone
I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any false statements, omissions, or misrepresentations on this application or false statements made during the employment process may be considered sufficient cause for rejection of this application, or dismissal if I have been employed, no matter when discovered by Buckingham Pavilion Nursing Center Inc. (Company).
I hereby authorize the Buckingham Pavilion to thoroughly investigate my background, references, employment record, and other matters related to my suitability for employment, without giving me prior notice of such disclosure. In addition I hereby release the company and all former employers and third parties from any and all claims or liabilities arising out of or related to such investigation or disclosure.
I understand that nothing in this application, or conveyed during any interview, is intended to create a contract. If hired, I understand that my employment is at-will, and can be terminated by me or by the Buckingham Pavilion at any time, with or without notice, and with or without cause. If hired, I agree to follow all work rules, policies, and procedures related to work performance and conduct.
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