* = Required Information
Application for Employment
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accomodation to the application and/or interview process should notify a representative of the Human Resource Department. For this type of employment, a criminal record check, health screening and drug screening is required as a condition of employment.
GENERAL INFORMATION
Please Print
Name
*
Last / First / Middle
Address
*
Street / City / State / Zip
Telephone #
*
Cellular/Other Phone
Email Address
*
SS#
We will use this information only for employment purposes and make reasonable efforts to safeguard your privacy.
Position(s) applied for
*
Date of application
Referral Source
(Please check the appropriate category and list the source.)
Walk-In
Employee
Advertisement
Company's Website
Other Internet
School
Job Fair
Other
If necessary, best time to call you is
Do you have access to adequate transportation to travel to and from work?
Yes
No
If you are under 18 and it is required, can you furnish a work permit?
Yes
No
If no, please explain
Driver's license number required if driving may be required in the job for which you are applying:
State
Please select state.
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Have you submitted an application here before?
Yes
No
If yes, give date(s) and position(s)
Will you work overtime if required?
Yes
No
If no, please explain
Have you ever been employed here before?
Yes
No
If yes, give dates
From
To
If they have been explained to you, are you able to meet the attendance requirements of the position?
Yes
No
NA
Do you have any relatives employed here?
Yes
No
If yes, provide name(s) and relationship(s)
Are you able to perform the "essential functions" of the job for which you are applying as provided on the job description (with or without reasonable accomodation)?
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 accomodation, or whether accomodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.
Yes
No
Are you eligible for employment in this country?
Yes
No
Have you ever been plead "guilty" or "no contest" to or been convicted of a crime?
Yes
No
If yes, please provide date(s) and details
Conviction will not necessarily be a bar to employment. Each instance and explanation will be considered in relation to the position for which you are applying.
What date are you available for work?
What is your desired salary range or hourly rate of pay?
$
Per
Type of employment desired
Full-Time
Part-Time
Shift desired (if applicable)
Day Shift
Eve. Shift
Night Shift
Any Shift
Will you travel if job requires it?
Yes
No
Registry, certification or professional license # (all registries, certifications, licenses must be in good standing)
#
State
#
State
#
State
Have you entered into an agreement with any former or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company?
Yes
No
If yes, please explain
List all states/counties in which you have worked and/or lived in the past ten (10) years
Education
Grade School
School Name
City, State
Major Course of Study
Checked Last Year Completed
1
2
3
4
Type of Diploma/Degree
High School
School Name
City, State
Major Course of Study
Checked Last Year Completed
1
2
3
4
Type of Diploma/Degree
Technical School
School Name
City, State
Major Course of Study
Checked Last Year Completed
1
2
3
4
Type of Diploma/Degree
College/University
School Name
City, State
Major Course of Study
Checked Last Year Completed
1
2
3
4
Type of Diploma/Degree
Graduate/Professional
School Name
City, State
Major Course of Study
Checked Last Year Completed
1
2
3
4
Type of Diploma/Degree
Employment History
Starting with your most recent employer, provide the following information
Employer
Phone
From
To
Address
Position
Duties
Supervisor's Name
Reason for Leaving
Starting Salary/Wage
May we contact for reference?
Yes
No
Final Salary/Wage
Employer
Phone
From
To
Address
Position
Duties
Supervisor's Name
Reason for Leaving
Starting Salary/Wage
May we contact for reference?
Yes
No
Final Salary/Wage
Employer
Phone
From
To
Address
Position
Duties
Supervisor's Name
Reason for Leaving
Starting Salary/Wage
May we contact for reference?
Yes
No
Final Salary/Wage
Employer
Phone
From
To
Address
Position
Duties
Supervisor's Name
Reason for Leaving
Starting Salary/Wage
May we contact for reference?
Yes
No
Final Salary/Wage
Explain any gaps in your employment, other than those due to personal illness, injury or disability.
If not addressed on previous section, have you ever been fired or asked to resign from a job?
Yes
No
If yes, please explain
Skills and Qualifications
Summarize any special skills, licenses and/or certificates that may assist you in performing the position in which you are applying
Check any categories listed below in which you have specialized training and/or skills
Activities
Administrative
Cash Register
Clerical/Secretarial
Computer
Dietary/Food Service
Driver
Housekeeping
Laundry
Maintenance
Nursing
Purchasing/Receiving
Security
Volunteer
References
List names and telephone numbers of three bussiness/work references who are
not
related to you and are
not
previous supervisors. If not applicable, list three school or personal references who are
not
related to you.
References 1
Name
Title
Relationship to You
Telephone
E-mail
# of Years Known
References 2
Name
Title
Relationship to You
Telephone
E-mail
# of Years Known
References 3
Name
Title
Relationship to You
Telephone
E-mail
# of Years Known
Is there any other job-related information you want us to know about you?
Request For Criminal Record Check
Name(Last, First, M.I)
*
Maiden/Alias
Date of Birth
*
Social Security Number
Sex
Male
Female
Address
*
I authorize the release of my criminal history record information to the requestor
Full Name
*
Purpose of this search is for employment in a Nursing Home
Please send reply to:
Cedargate Healthcare Group
2350 Kanell Blvd.
Poplar Bluff, MO 63901
Tele: 573-785-0188
Fax: 573-785-7321
Email: Ssmall@cedargatehc.com
I verify the above named person has received a copy of "A Summary of Your Rights under the Fair Credit Reporting Act"
Signed
Printed: Sherrie Small, Administrator
Submit