Fields marked with an asterisk (*) must be filled out before submitting.


EMPLOYMENT DESIRED

Position or type of work *
 
Seeking Full Time
Part Time
Per Diem Pool
Temporary
Summer
Weekend Option
Day
Evening
Night
Weekends
Holidays
Live In
 
Are you available to work weekends? Yes
No

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PERSONAL INFORMATION

Last Name *
First Name *
Middle Name
City
Other names by which you have been employed
Email Address *
Address
State
Zip
Telephone Number
Alternate Phone where you maybe contacted
 
Are you 18 years of age or older? Yes
No
 
Do you have a legal right to work in the US? Yes
No
 
 
How did you learn about us? Newspaper ad
Other publication
Job fair/open house
School
Facility employee
Other
 

Have you previously been employed by Coulterville Care Center
Tower Grove Manor
Brooking Park
The Sarah Community
Good Samaritan Home
St. Andrews At-Home Services
Mizpah Manor
New Florence Nursing & Care Center
Cape Albeon
St. Andrews Management Services
St. Andrews Apartments
St. Pauls Home
Dates employed at the above employers
From
To

List any relatives who are currently employed by our facility

Relative Name
Relationship
Department
 
Relative Name
Relationship
Department

May we share your application with other St. Andrews communities? Yes
No
 
Do you have the ability to perform the essential functions of the position for which you are applying? Yes
No
If no, please explain:
 
Indicate any reasonable job accommodations that may be made to better enable you to perform the duties of the job for which you are applying:
Have you ever been convicted of a felony? Yes
No
If yes, give details
Conviction does not necessarily disqualify you for employment. The nature of the crime, date of conviction, and extenuating circumstances are considered.
 

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EMPLOYMENT HISTORY

Please list your job history for the past ten years or last four employers, starting with your present or most recent employment. Include military service. Do not include internships or explanations of periods of unemployment. Include those in Additional Information section below.

Most recent or current employer:

Employer Name
Employer Address
Employed From
To
Last Salary
Immediate Supervisor
Name
Title
Phone
If present employer, may we contact? Yes
No
Status FT
PT
As needed
Position Title
Describe your principal duties or responsibilities
Reason for leaving

Previous Employer

Employer Name
Employer Address
Employed From
To
Last Salary
Immediate Supervisor
Name
Title
Phone
If present employer, may we contact? Yes
No
Status FT
PT
As needed
Position Title
Describe your principal duties or responsibilities
Reason for leaving

Previous Employer

Employer Name
Employer Address
Employed From
To
Last Salary
Immediate Supervisor
Name
Title
Phone
If present employer, may we contact? Yes
No
Status FT
PT
As needed
Position Title
Describe your principal duties or responsibilities
Reason for leaving

Previous Employer

Employer Name
Employer Address
Employed From
To
Last Salary
Immediate Supervisor
Name
Title
Phone
If present employer, may we contact? Yes
No
Status FT
PT
As needed
Position Title
Describe your principal duties or responsibilities
Reason for leaving

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EDUCATION

High School
High School Name
City
Dates Attended
Graduated Yes
No
If GED, date received

College or other school
Location (city/state)
Did you graduate? Yes
No
Diploma, degree, or certificate
Course of study

College or other school
Location (city/state)
Did you graduate? Yes
No
Diploma, degree, or certificate
Course of study

College or other school
Location (city/state)
Did you graduate? Yes
No
Diploma, degree, or certificate
Course of study

College or other school
Location (city/state)
Did you graduate? Yes
No
Diploma, degree, or certificate
Course of study

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PROFESSIONAL LICENSURE, REGISTRY, CERTIFICATION

Type of license, registry or certification
Issuing state or organization
Number
Expiration date

Type of license, registry or certification
Issuing state or organization
Number
Expiration date

Type of license, registry or certification
Issuing state or organization
Number
Expiration date

If not currently registered, licensed or certified, are you eligible? Yes
No
When will/did you sit for your examination?

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SPECIAL SKILLS

Skills Personal Computer
Word Processing
CRT
Home Health Aide
CNA
Homemaker
Housekeeping
Escort
Typing
Transcription
Shorthand
Medical Terminology
 
Hardware used
Software used
Other special skills

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Additional Information

Please include any additional information that you think would be applicable (eg. internships, membership in professional organizations, additional relevant employment, and explanation of any gaps in employment). Exclude any information that would denote race, sex, age, marital status, national origin, religious or political affiliations.
Additional Information

*****************************************

Personal References

Name
Address
Phone Number

Name
Address
Phone Number

Name
Address
Phone Number

Name
Address
Phone Number

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Please read carefully before submitting

Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital, ancestry, sexual orientation or veteran status, or the presence of a disability or handicap.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application or any other pre-employment documents shall result in termination when discovered. I authorize you to obtain an investigative consumer report and/or a report from any law enforcement agency which may include both general and personal information about me if I am offered employment or at any time during my employment. I authorize investigation of all statements con- tained herein and authorize the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

In consideration of my employment, I agree to conform to the rules and regulations of the Company and agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either the Company or myself and without notice or liability for wages or salary except such earned at the date of such termination. I understand that no manager, supervisor or representative of management, other than the President (or ranking officer), has any authority to enter into an agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.

In the event that I am employed, I understand that regardless of the shift and job that I am first assigned, I may be required to accept a change of job or shift depending on my demon- strated skills after employment and the needs of the Company. I consent to take any physical or medical examinations, including blood and urine or other tests for alcohol and drugs, requested by the Company in connection with the processing of my application for employment and further agree to take any such physical or medical examinations requested by the Company during my employment if I am offered and accept a job. I understand that such an examination may be needed in order to determine my competence to perform the job or work for which I was hired, or to identify any physical or mental condition bearing on my job performance. I understand that refusal to submit to any physical or medical examination ordered by the Company will result in rejection for employment or for disciplinary action up to and including immediate discharge. I further understand that any information obtained through such exams may be retained by the Company and is exclusively the Company’s property. I also understand that the examinations will be performed by medical personnel, clinics or labo- ratories qualified to do the necessary work and costs for such examinations will be borne by the Company.

I understand that The Sarah Community is tobacco free and has policies and procedures governing such and agree to abide by those policies if I am employed by The Sarah Communiity.

I agree * Yes
No