Application for Employment
Personal Information
Potential employees will receive full consideration without regard to race, creed, color, sex, age, national origin, handicap, or veteran status.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Middle Name
Last Name
Former Last Name(s) You Were Known By:
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
-
Area Code
Phone Number
Social Security Number
*
Have you ever applied for employment with us before?
*
Yes
No
If Yes, when?
Have you ever worked for the Village before?
*
Yes
No
If Yes, when?
What encouraged you to apply here?
Relative
Friend
Agency
Other
Employee
If employee referral, Name of Employee:
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Work Interest
Position Desired & Wage Expected
*
Do you agree to work any shift you are assigned?
*
Yes
No
If no, explain
Will you work Saturday and/or Sunday when your work schedule requires?
*
Yes
No
If no, explain
Availability
*
Full Time
Part Time
Permanent
Temporary
Are you eligible for employment in the United States?
*
Yes
No
When are you available to begin work?
Special Training or Skills
Have you ever been convicted of a crime (other than minor traffic violations)?
*
Yes
No
If yes, list all convictions (felony and misdemeanor) showing offense and date.
Have you ever been accused and found guilty of abusing, neglecting, or mistreating a resident/patient?
*
Yes
No
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Education and Training
Nursing License / Certification
CNA
LPN
RN
State of License / Certification
License / Certification #
School #1
Graduate
College
Business/Trade/Tech
High School
Name of School / Course of Study
Number of Years Complete
1
2
3
4
Degree or Diploma
Degree
Diploma
School #2
Graduate
College
Business/Trade/Tech
High School
Name of School / Course of Study
Number of Years Complete
1
2
3
4
Degree or Diploma
Degree
Diploma
Do you attend school now?
Yes
No
Do you plan to continue your education?
Yes
No
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Employment
1. Company Name / Supervisor Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Employed From - To (Month and Year)
Job Title
Reason for Leaving
Can we contact this employer?
Yes
No
2. Company Name / Supervisor Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Employed From - To (Month and Year)
Job Title
Reason for Leaving
Can we contact this employer?
Yes
No
3. Company Name / Supervisor Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Employed From - To (Month and Year)
Job Title
Reason for Leaving
Can we contact this employer?
Yes
No
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Work References
(Do not include relatives or employers listed in the Employment section.)
Reference 1
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Occupation
Years Known
Reference 2
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Occupation
Years Known
Reference 3
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Occupation
Years Known
Signature
*
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Supplement to Application for Employment
The following information may be answered on a voluntary basis and will be maintained in a separate confidential file from the application of employment. The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex, or national origin. Federal law also prohibits discrimination based on age, citizenship, and disability.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Position Applied For
Social Security Number
Marital Status
Single
Engaged
Married
Seperated
Divorced
Widowed
Are you a Vietnam veteran?
Yes
No
Are you a disabled veteran?
Yes
No
What was your previous address?
How long at present address?
How long at previous address?
Are you a U.S. Citizen?
Yes
No
Are you over 18 years of age? If not, employment is subject to verification of age.
Yes
No
Names of relatives and friends working at The United Methodist Village.
Submit
Should be Empty: