Application for Employment Form pg1
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PARKLANE NURSING HOME
EMPLOYEE APPLICATION
INSTRUCTIONS: It is the policy of this company to provide equal opportunity with regard to all terms and conditions of employment and conditions of employment. The company complies with federal and state laws prohibiting discrimination on the basis of race, color religion, creed national origin, disability, veteran status, age, or any other protected characteristic.
Date of application:
xx/xx/xxxx
Name: Home Phone:
xxx-xxx-xxxx
Cell/Other Phone::
xxx-xxx-xxxx		 Email:
Address:
City/State/ZIP:
Position applied for:
Shift Preferred: 1 2 3 Any Not Applicable
Expected salary range or hourly rate of pay: $
Type of work desired: Full Time Part Time Seasonal Temporary
Date Available: xx-xx-xxxx
Referred by:
Have you been employeed here before?: Yes No
Is this application a request for reemployment following
an extended military leave of absence from this company?
If yes, additional information may be requested.		 Yes No
If you are under 18 years of age, can you provide a work
permit if required?		 Yes No
Are you legally eligible for employment in the USA?
If yes, proof is required if hired.		 Yes No
Are you able to perform the "essential functions" of the
jobfor which you are applying (with or without
reasonable accommodation)?
This question is not designed to elicit information about an
applicant's disability. Please do not provide information
about the existence of a disability, particular accommodation
or whether accommodation is necessary. These issues may
be addressed at a later stage to the extent permitted by law.		 Yes No Need more information
about the job's essential
functions" to respond?

Yes No

Will you relocate if required? Yes No
Will you travel if required? Yes No
Will you work overtime if required? Yes No
If driving may be required in the job for which you are
applying, please provide your driver's license number.		 DR #: State:
Have you ever been bonded? Yes No
Page 1

EMPLOYMENT EXPRIENCE
Place a check in the box by the employer(s) you do not want us to contact. List your most recent employer first.
1. Employer:
Address:
Job Title: Supervisor:
E-Mail:
Date Employed: From (mm/yy)
 To (mm/yy)
 Hourly rate/salary:
 Starting:
 Final:
Work Performed:
Reason for leaving:
2. Employer:
Address:
Job Title: Supervisor:
E-Mail:
Date Employed: From (mm/yy)
 To (mm/yy)
 Hourly rate/salary:
 Starting:
 Final:
Work Performed:
Reason for leaving:
3. Employer:
Address:
Job Title: Supervisor:
E-Mail:
Date Employed: From (mm/yy)
 To (mm/yy)
 Hourly rate/salary:
 Starting:
 Final:
Work Performed:
Reason for leaving:
4. Employer:
Address:
Job Title: Supervisor:
E-Mail:
Date Employed: From (mm/yy)
 To (mm/yy)
 Hourly rate/salary:
 Starting:
 Final:
Work Performed:
Reason for leaving:

Explain any gaps in employment other than those due to personal illness, injury or disability.
Have you ever been fired or asked to resign from a job? Yes No

EDUCATIONAL BACKGROUND
High School: Years completed:
Name of school:
Location:
Course of study: Did you graduate? Yes No
Degree or diploma? Yes No
College: Years completed:
Name of school:
Location:
Course of study: Did you graduate? Yes No
Degree or diploma? Yes No
Vocational Training: Years completed:
Name of school:
Location:
Course of study: Did you graduate? Yes No
Degree or diploma? Yes No
Continuing Education:

SKILLS & QUALIFICATIONS
List any special training skills, licenses and/or certificates that may assist you in performing the position for which you are applying:
Computer Skills: (Check appropriate boxes, include software titles and years of experience.)
Word Processing: Years: Internet: Years:
Spreadsheet Years: Other: Years:
Presentation Years: Other: Years:
E-mail: Years: Other: Years:
Is there any other job-related information you want us to know about you?

REFERENCES
List names and telephone numbers of three business/work references who are not related to you and are not previous
supervisors. If not applicable, list three school or personal references whom are not related to you.
Name Title Relationship
to you		 Telephone E-mail Yours known

APPLICANT STATEMENT
I certify that all of the information submitted by me on this application is true and complete, and I understand that if any false or misleading information, omissions, or misrepresentations are discovered , my application may be rejected and if I am employed, my employment may be terminated at any time.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references
(personal and professional), employers, public agencies, licensing authorities institutions and to otherwise verify the accuracy of all information provided
by me in this application, resume' or job interview. I hereby waive any and all rights and claims I may have regarding the employer, it's agents, employees
or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other
personals, corporations or organizations for furnishing such information about me.

I understand that this application remains active for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish
to be considered for employment, it will be necessary for me to reapply and fill out a new application.

In consideration of my employment, I agree to conform to the company's rules and regulations, and I understand that these rules and/or the employee
handbook do not form a contract of employment, either express or implied and I agree that my employment and compensation can be terminated, with
or without cause and with or without notice, at any time, at either my or the company's opinion. I also understand and agree that the terms and conditions
of my employment may be changed, with or without cause and with or without notice, at any time by the company. I understand that no company
representative, other than it's president, and then only when in writing and signed by the president, has any authority to enter into any agreement for
employment for any specific period of time, or to make any agreement contrary to the foregoing.
Applicant's Signature:
Today's Date: