Employment Application Position Applying For: * RequiredName: * Required First Last Date of Birth: - must be mm/dd/yyyy format * Required Address: * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email: * Required Phone: * RequiredEmergency Contact: First Last Emergency Contact Phone:Relationship to Emergency Contact:Registration # for Nurses/Medtechs/CNA:State of Registration for Nurses/Medtechs/CNA:Are you currently under investigation for resident abuse, neglect, mistreatment of property, or have a finding entered against you into a State Nurses Aide Registry? * RequiredYesNoHave you ever been convicted of a felony or a crime? * RequiredYesNoDo you have any specialized training for the position for which you are applying? * RequiredYesNoWhere did you receive your training:Have you ever worked for us before? * RequiredYesNoApproximate date of employment:What was your reason for leaving?If hired, can you provide proof of age and citizenship? * RequiredYesNoWhat prompted you to apply for this position?Education Information Name of high school:Location of high school:Number of years to complete high school:Name of college:Location of college:Number of years to complete college:College major or degree:If applicable, please list the name:List any other school experience not previously listed. Examples: business or trade school, professional school, etc. References (Not Relatives) List up to three below. Reference #1 Name: First Last Reference #1 Address:Reference #1 Phone:Reference #1 BusinessReference #1 Years Known:Reference #2 Name: First Last Reference #2 Address:Reference #2 Phone:Reference #2 BusinessReference #2 Years Known:Reference #3 Name: First Last Reference #3 Address:Reference #3 Phone:Reference #3 BusinessReference #3 Years Known: Employment History List up to three past employers below. Employer #1 Name:Employer #1 Address:Employer #1 exact title of your position:Employer #1 rate of pay:Employer #1 date start (MM/YYYY):Employer #1 date end (MM/YYYY):Employer #1 Supervisors Name:Employer #1 Phone:May we contact Employer #1?YesNoDuties (Be Specific) of Employer #1:Reason for leaving from Employer #1:Employer #2 Name:Employer #2 Address:Employer #2 exact title of your position:Employer #2 rate of pay:Employer #2 date start (MM/YYYY):Employer #2 date end (MM/YYYY):Employer #2 Supervisors Name:Employer #2 Phone:May we contact Employer #2?YesNoDuties (Be Specific) of Employer #2:Reason for leaving from Employer #2:Employer #3 Name:Employer #3 Address:Employer #3 exact title of your position:Employer #3 rate of pay:Employer #3 date start (MM/YYYY):Employer #3 date end (MM/YYYY):Employer #3 Supervisors Name:Employer #3 Phone:May we contact Employer #3?YesNoDuties (Be Specific) of Employer #3:Reason for leaving from Employer #3:Agreement to terms: * RequiredI understand that I will be given a criminal background check, physical examination, drug screen and TB skin test. I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts asked for is cause for dismissal. Oak Ridge Care Center, Inc. cannot guarantee you or any employee continued employment for any definite period of time. You have the right to terminate your employment at any time. Oak Ridge Care Center, Inc. retains the same right to terminate your employment with or without cause. YOU ARE ALL AT-WILL EMPLOYEES (THAT IS YOU CAN BE FIRED AT ANY TIME FOR ANY REASON NOT IN VIOLATION OF FEDERAL OR STATE LAW WITHOUT OAK RIDGE CARE CENTER, INC. HAVING TO SHOW “JUST CAUSE” FOR THE DISCHARGE). I also agree, if employed, to abide by the policies established by Oak Ridge Care Center, Inc. I AgreeNameThis field is for validation purposes and should be left unchanged.