Nursing Application Employment Application Date of Application * Personal Information Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * General Information Position Applying For Salary Desired Date Available to Start MM DD YYYY Available * Full-Time Part-Time Shift Desired * Day Evening Night Relief All Are you available to work weekends? * Yes No Are you under 18, can you provide a work permit if offered a job? * Yes No If you are not a U.S. citizen, do you have the right to work in the U.S.? * Yes No Have you ever applied for a position with or worked for Solheim Senior Community before? * Yes No If yes, please specify dates Do you have any friends or relative working for Solheim Senior Community? * Yes No If yes, state name(s) and relationship: Please give the name of the current employee who referred you to Solheim: Education High School Address Years Completed Did you graduate? Option One Option Two If attended College, name of school Address Major Years Completed Did you graduate? If attended Vocational Business School, name of school Address Major Years Completed Did you graduate? Do you speak a foreign language? If so, please list which languages Are you licensed/certified for the job applied for? * Yes Now Name of License / Certification Issuing State License/certification number Has your license/certification ever been revoked or suspended? Yes No If yes, state reason(s), date of revocation or suspension and date of reinstatement To assist us to check records and to verify prior employment and education, please indicate whether you were ever employed or enrolled in a school under a name other than that used on this application Yes No If yes, please specify the name you were employed or enrolled under Are you able to perform the essential duties of the position for which you are applying, either with or without reasonable accommodations? * Yes No If no, please describe the function that cannot be performed Please list any job-related professional, trade, business or civic activities, organizations and associations. (You may omit those which indicate race, color, religion, national origin, ancestry, sex, age, or the existence of a disability) Employment History If you are employed now, may we contact your employer? * Yes No Name of Employer Start Date MM DD YYYY End Date MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number (###) ### #### Position Supervisor Description of Duties Reason for leaving Name of Employer Start Date MM DD YYYY End Date MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Position Supervisor Description of Duties Reason for leaving Please identify and explain all periods of unemployment in excess of one month during the past 10 years: Period of Unemployment (xx/xxxx - xx/xxxx) Reason for unemployment Period of Unemployment (xx/xxxx - xx/xxxx) Reason for unemployment Please provide the names, telephone numbers, and number of years acquainted of at least three professional references who are not related to you Name, Phone Number, Years Acquainted Name, Phone Number, Years Acquainted Name, Phone Number, Years Acquainted * I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the statements checked by Solheim unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals whom Solheim contacts, to provide Solheim any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to Solheim as well as from any use or disclosure of such information by Solheim or any of its agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, my immediate dismissal from employment. In consideration of my employment, I agree to conform to the rules and standards of Solheim. I further agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice, at any time, either at my option or at the option of Solheim. I understand that no employee or representative of Solheim, other than its Executive Director, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Further, the Executive Director of Solheim may not alter the at-will nature of the employment relationship unless the Executive Director and I both sign a written agreement that clearly and expressly specifies the intent to do so. I agree that this constitutes an integrated agreement with respect to the at-will nature of my employment relationship, that it is final and fully binding, and that there are no oral, written, or collateral agreements regarding this issue. I also understand that all offers of employment are conditioned on the provision of satisfactory proof of an applicant's identity and legal authority to work in the United States, as well as the satisfactory completion of a post-offer medical examination. Yes EEO APPLICANT FLOW DATA FORM Dear Applicant: Federal and state rules require that we keep applicant flow data in our records for statistical purposes. Employers are asked to solicit this information from applicants on a purely voluntary basis. The information is not used for any employment decision. If you wish to provide this information, please do the following: 1. Do not place your name on this page 2. Enter the date below 3. Check the applicable boxes and enter your date of birth This form will not be kept with your employment application. Today's Date MM DD YYYY Position applied for Choose one Caucasian (not of Hispanic origin) Black (not of Hispanic origin) Hispanic Asian or Pacific Islander American Indian or Alaskan Native Other Prefer not to disclose FileField;MaxSize=5120;Multiple;addText=Add_your_Resume_Here!; Resume Attached? * Yes No Thank you!
