Employment Form | East Side Nursing

Personal Information

Last Name:

First Name:

MI:

SSN# (Last 4):

Address:

Cell Phone:

Best Time to Call:

Home Phone:

Best Time to Call:

Are You Entitled to work in the United States?

Yes

No

Position Applying For:

If you served in the United States Military, please state if you received any training or experience that would assist you in performing the job for which you applied:

Have you been convicted of a crime?

Yes

No

If yes, please explain:

Referred by:

Applying for:

Full Time

Part Time

Are you at least 18 years of age?

Yes

No

Under age 18, do you have a work permit?

Yes

No

What other name have you been known by?

How did you hear of the position?

Shift Preference?

7am - 3pm

3pm - 11pm

11pm - 7am

Date Available:

Provide name(s) of family or friend(s) currently employed at Eastside Nursing & Rehabilitation Center:

Have you submitted an application with our company before?

Yes

No

If yes, provide the application date:

Have you ever been employed by our company?

Yes

No

If yes, provide employment dates:

From:

To:

Prior Work Experience

Current or Most Recent

Employer:

Address:

Phone:

Name of Immediate Supervisor:

Position/Job Title:

Dates of Employment

From:

To:

Pay:

Reason for Leaving:

May We Contact?

Yes

No

Prior

Employer:

Address:

Phone:

Name of Immediate Supervisor:

Position/Job Title:

Dates of Employment

From:

To:

Pay:

Reason for Leaving:

May We Contact?

Yes

No

Prior

Employer:

Address:

Phone:

Name of Immediate Supervisor:

Position/Job Title:

Dates of Employment

From:

To:

Pay:

Reason for Leaving:

May We Contact?

Yes

No

Education

High School

Name/Location:

Last Year Complete:

9

10

11

12

Degree:

Major or Emphasis:

College/University

Name/Location:

Last Year Complete:

1

2

3

4

Degree:

Major or Emphasis:

Trade School

Name/Location:

Last Year Complete:

Degree:

Major or Emphasis:

Other

Name/Location:

Last Year Complete:

Degree:

Major or Emphasis:

List any applicable special skills, training or proficiencies.

RN License #:

LPN License #:

CNA Registry:

Expiration Date:

Personal References

Reference 1

Name:

Address:

Telephone:

Reference 2

Name:

Address:

Telephone:

Reference 3

Name:

Address:

Telephone:

Have you ever had a non-criminal finding of abuse, neglect or misappropriation of resident funds sustained against you?

Yes

No

Is there currently a non-criminal on going investigation of abuse, neglect or misappropriation of resident property that involves you?

Yes

No

If so, please describe fully the facts of the investigation:

APPLICANT'S STATEMENT:

Signature

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