Employment Application

PERSONAL INFORMATION
Date Available
First*
Middle
Last*
Present Address
Street Address Address Line 2 City State ZIP Code
Permanent Address
Street Address Address Line 2 City State ZIP Code

(Please fill out if different than present address)
Phone*
Alternate Phone
*If you cannot be reached at above phone number, please give alternate number.

EMPLOYMENT RECORD
(list last or present position first)
Name of Company
Address
Street Address Address Line 2 City State ZIP Code
Dates of Employment

Start Date
End Date

End Date
Supervisor's Name
Phone
Salary Range (Starting and Ending)
Position Held
Name of Company
Address
Street Address Address Line 2 City State ZIP Code
Dates of Employment

Start Date
End Date

End Date
Supervisor's Name
Phone
Salary Range (Starting and Ending)
Position Held
Name of Company
Address
Street Address Address Line 2 City State ZIP Code
Dates of Employment

Start Date
End Date

End Date
Supervisor's Name
Phone
Salary Range (Starting and Ending)
Position Held
If your former employment references, education or military service are under a name other than indicated on front of application, please indicate it here

Last, First, Middle
Have you ever been convicted of a crime?
- Yes
- No
If Yes, for what, when and where?

(Conviction of a criminal offense will not necessarily preclude your employment)
Use this space to give us further information which will assist us in placing you, including at least two personal references not related to you, whom you have known at least one year.

Employment Understanding (Please Read and Sign)
This institution does not discriminate in hiring or, any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination. I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential duties I would be required to perform. I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time with cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence identity and eligibility for employment.
Applicant Signature
First Last
Typing your name above will constitute as your legal signature.
Date
MM slash DD slash YYYY
Please Indicate Days and Hours You Are Available For Work (Be Specific)
Please list your available times (include both AM and PM). List all days of the week including Saturday and Sunday.
Availability Record

Primary position desired
Will you accept another position?
- Yes
- No
If so, what?
Are you available to work:
- Weekends?
- Holidays?
- Rotating Shifts?
If your availability changes, it is your responsibility to fill in an "Availability Card" indicating the changes. Such changes will be effective, then, for any future employment.
Applicant Signature
First Last
I understand that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as directed by my department head or administrator of this institution. By typing your name above it counts as your legal signature.
Resume
Accepted file types: pdf, Max. file size: 29 MB.
Please attach your resume here. PDF files only. Thank you!
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PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION

PROFESSIONAL LICENSES AND/OR CERTIFICATIONS

EMPLOYMENT RECORD

Employment Understanding (Please Read and Sign)

Avoyelles Manor Nursing Home