Position Applying For:*

Name:*

First Last

Address:*

Street Address Address Line 2 City State ZIP Code

Email:*

Phone:*

Emergency Contact:

Emergency Contact Phone:

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?*

Yes
No

If hired, can you provide proof of age and citizenship?*

Yes
No

What prompted you to apply for this position?

References (Not Relatives)

List up to two below.

Reference #1 Name:

First Last

Reference #1 Address:

Reference #1 Phone:

Reference #1 Business

Reference #1 Years Known:

Reference #2 Name:

First Last

Reference #2 Address:

Reference #2 Phone:

Reference #2 Business

Reference #2 Years Known:

Employment History

List up to three past employers below.

Employer #1 Name:

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?

Yes
No

Reason for leaving from Employer #1:

Employer #2 Name:

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?

Yes
No

Reason for leaving from Employer #2:

Employer #3 Name:

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?

Yes
No

Reason for leaving from Employer #3:

Agreement to terms:*

I 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. Hope Health & Rehabilitation 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. Hope Health & Rehabilitation 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 Hope Health & Rehabilitation Center, Inc.

I Agree

Contact Info

Employment Application

References (Not Relatives)

Employment History