Carlin House Assisted Living

Carlin House Assisted Living

Electronic Employment Application
Please complete this form to successfully submit your employment application to Carlin House Assisted Living.
This application uses HTML formatting & electronic signature "eSign" technology.

© 2022 Cody Bailey, CCNA Development Director & Network Administrator.
Applicant Information

*Please enter all required information below truly and correctly.
*Legal First Name:*
Middle Initial:
Please select your middle initial if applicable.
*Legal Last Name:*
E-mail*
Your Primary Email Address
*Primary Phone Number:*
primary phone
Secondary Phone Number:
* Skip if does not apply *
SSN:*
Social Security Number
Date/Time Application Filled:

MonthDayYear
DateHourMinutesAM/PM Option
If you have previously used an alternate name (other than listed above) please provide below.
If you have not used an alternate name, please skip this question.
Street Address:*
Apt / Unit #
City:*
State:*
ZIP:*
5-Digit Zip Code ↑ ↑

General Employment Information

Please provide all required information
Position you are applying for:*
Select From List. *You may select more than one position of interest that you wish to apply for as an alternative. (Please select the primary position first).
If you selected "other" - please provide your position of interest:
* Skip this question if it does not apply *
What is your desired salary?*
Your Desired Salary.
Date you would be able to start work:*

MonthDayYear
Date Available
Which shift are you willing to work?*
Select from the list
Desired Status:*
Select from the list
How did you hear about us?*

Internet SearchCarlin House WebsiteFacebook / Social MediaNewspaperCurrent Carlin House EmployeeOther
If you were referred by a current employee, please provide their name below:
Current Employee Who Referred You.
Have you worked for Carlin House in the past?*

YesNo
If you have worked for Carlin House in the past, when?
If you have not worked for Carlin House in the past, please type “N/A”
{legalFirst},

You're off to a great start! Let's continue by selecting the "Continue" button below!

Applicant Personal Information

Eligibility & Violation History
Have you been a resident of Ohio for at least 5 years?*

YesNo
If you have NOT been a resident of Ohio for at least 5 years, please select your former state of residence:
Are you legally able to work in the United States?*

YesNo
Have you ever been convicted of a law violation(s), including moving traffic violation(s), but excluding offenses committed before your eighteenth (18) birthday?*

YesNo
If you have been convicted of a law violation(s), including moving traffic violation(s), but excluding offenses committed before your eighteenth (18) birthday, please explain below:
(Type “N/A” and skip if you have had zero violations)

Education & Academic History

High School, Post-High School, Vocational, College, Etc.
Please complete the questions below. This section will identify any academic foundations you've attended, as well as any certification(s) or licenses you currently hold.
What is the highest grade you completed? (Select from the drop-down list)*
How many years of post-high school education have you completed?*
Name of High School:
High School Address:
High School Start Date:

MonthDayYear
Date
High School End Date:

MonthDayYear
Date
Degree:
Did you graduate?

YesNo
Name of College:
Address of College:
College Start Date

MonthDayYear
Date
College End Date:

MonthDayYear
Date
Degree:
Did you graduate?

YesNo
Vocational / Other Name:
Vocational / Other Address:
Vocational / Other Start Date:

MonthDayYear
Date
Vocational / Other End Date:

MonthDayYear
Date
Vocational / Other Degree:
Did you graduate?

YesNo

Education Information Continued

Additional Education Anticipation, Skills, Etc.
If you expect to complete an educational program in the near future, please indicate what type of degree or program, and your expected completion date:
List additional information you feel would help evaluate your employment application:*
List any office equipment with which you are familiar:
List any licenses/certifications you currently hold which would be required for a certain position:

Professional References

Please list three (3) professional references (whom are non-relatives)
Reference 1 Full Name:*

First NameLast Name
Relationship:*
Years Known:*
Address:
Phone Number*
Reference 2 Full Name:*

First NameLast Name
Relationship:*
Years Known:*
Address:
Phone Number:*
Reference 3 Full Name:*

First NameLast Name
Relationship:*
Years Known:*
Address:
Phone Number:*

Previous Employment Experience

Employment History | *Please begin with most recent
Company:
Phone Number:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Reason for Leaving:
May we contact this employer for a reference?

YesNo
Company:
Phone Number:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Reason for Leaving:
May we contact this employer for a reference?

YesNo
Company:
Phone Number:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Reason for Leaving:
May we contact this employer for a reference?

YesNo

Disclaimer, Certification, e-Signature

You are almost finished! Please review the following disclaimer(s) and certification(s)
CERTIFICATION ─*
E-Signature Disclaimer ─*
e-Signature*

Clear
Use the area above to sign your signature electronically
Should be Empty: