Today's Date: (IE:4/28/2008)    Expected Rate of Pay: (IE: 7.99)   Date Available: (IE: 4/28/2008)

Type of Employment you are seeking? Full TimePart Time Pool/PRN   

Please choose the position(s) you are applying for: CNA CNA CLASS SOCIAL ACTIVITIES RN HOUSEKEEPING MAINTENANCE DIETARY COOK MEDICAL RECORDS ANY AVAILABLE LPN LAUNDRY

First, Middle and Last  Name:      Social Security Number (ie:xxx-xx-xxxx)

Address:  City: State:   Zip Code:

Are  you 18 years of age or older? Yes No (If under 18, applicant will be required to submit a certificate as required by state and federal law)
Do you have adequate, dependable transportation? Yes No     Do you have required uniforms? Yes No
 

• EDUCATION
  Check the highest level of equivalence of education completed: (choose one)
  High School 9 10 11 12   College/Technical 1 2 3 4   Diploma/Degree Obtained? Yes No

          Name and location of college, university or Vo-tech attended:

• BACKGROUND
  Have you ever been convicted of a felony? Yes No
  (We complete criminal background checks on all new hires and required by Care Provider Elderly Disabled Act 990 of 1997)
  Have you ever been disciplined, reprimanded or had legal action against you for violent behavior? Yes No
  Have you ever been convicted of any type of theft or fraud? Yes No  If yes, identify the crime for which you were convicted. Please provide
  details  you feel are relevant. Conviction of a crime will not automatically disqualify you from consideration for employment, but will be considered as a part of an overall evaluation or your qualifications.
  
  (1000 characters maximum)
  
  (If assistance in the application or hiring process is needed to accommodate a disability, please contact us)
   

• EMPLOYMENT HISTORY
  Starting with your present employer, list your entire employment history. For any unemployed or self-employed periods,
  show dates and location.

  1. Dates of Employment     From to	2. Dates of Employment     From to	3. Dates of Employment     From to
  Names and Address of Company:         Phone:                (xxx-xxx-xxxx)     Position:    Supervisor's Name:        Last Rate of Pay: $/hr Reason for Leaving: 250 characters maximum	Names and Address of Company:         Phone:                (xxx-xxx-xxxx)     Position: Supervisor's Name:      Last Rate of Pay: $/hr Reason for Leaving: 250 characters maximum	Names and Address of Company:          Phone:                (xxx-xxx-xxxx)      Position: Supervisor's Name:      Last Rate of Pay: $/hr Reason for Leaving: 250 characters maximum
  If currently employed, may we contact your current employer? Yes No

• REFERENCES
  List 3 people (no relatives), with whom you have worked or have known, as it relates to your work history.

• AVAILABILITY (Choose all that apply)
  Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday Anytime
  Shifts available: 6am-2pm 2pm-10pm 10pm-6am PRN/CALL Anytime

• IMPORTANT (PLEASE READ CAREFULLY)
  We are glad you are interested in joining us in this important work. Please read the following statement carefully before you submit you submit this application.
  
  The company, in considering my application for employment, may verify the information set forth on this application and obtain additional background information where legal relating to my background. I authorize all persons, schools, employers, companies, corporations, credit bureaus, CAN Registry, OLTC Employment Registry and law enforcement agencies to supply any information concerning my background. I HAVE READ AND UNDERSTAND AND AGREE TO THIS STATEMENT. By initialing, I am giving my electronic signature to the above.
  PLACE YOUR INITIALS HERE:

          I certify that the information on this application is correct and I UNDERSTAND that any misrepresentation or omission of any information will
          in my disqualification from consideration for employment, or if employed, my dismissal. I understand that this application is not a contract,
          offer, or promise of employment, and if hired, I will be able to resign at any time for any reason. Likewise, the facility can terminate my
          employment at any time without reason. I further understand that no on has the authority to enter into an employment contract or
          agreement with me, and that my at will employment can be changed only by a written agreement by the Administrator.

          I HAVE READ AND UNDERSTAND AND AGREE TO THIS STATEMENT: (PLACE INITIALS HERE)

          I understand that this application is good for only sixty (60) days from today's date. If I still desire a position with the company after
          this application expires, it will be my responsibility to fill out a new application and return it here. Otherwise, the company will not
          consider me for employment after this application expires.

          PLEASE PLACE YOUR INITIALS HERE AND THEN CLICK SUBMIT: