Personal Information Employment History Education History References Applicant Attestations Summary and Submit Name Application for Employment We are an Equal Opportunity Employer Position Applying For: * RN Marketing Driver PCA Therapy Housekeeping Accounting Clerical Dietary Maintenance Other Do you know of any restrictions, personal or otherwise, which would restrict the hours you can work? * NoYes What date can you begin work? * Referral Source: * Advertisement Relative Walk-In Government Agency Employee Other If Employee or Other, Please Provide Name: Your Information First Name * Last Name * Address * State * Pennsylvania Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware 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 Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming How long have you resided at this address? * City * Zipcode * Have you lived in any place other than Pennsylvania in the past three (3) years? * NoYes Social Security Number * Date of Birth * Email Address * Emergency Number Cell Number Phone Number Are you protected from lawfully becoming employed due to Visa or Immigration status? * NoYes Do you have Working Papers? * NoYes Are you over 18? * YesNo Employment History Employer #1 Employer Name Employer Address Employer Phone Start Date End Date Position Held Start Salary End Salary Immediate Supervisor Reason for Leaving Summary of Duties May we contact Employer #1 * YesNo Additional Employment History? Yes Education History Institution #1 Institution Name Start Date End Date Diploma/Certificate/Degree Received Diploma Certificate Degree Diploma/Certificate/Degree Name Institution Address Institution Phone Instructor Reference Pertinent subjects/skills learned May we contact this institution? Yes Additional Education History? Yes References Reference #1 Reference Name Years Known Phone Relationship Address Reference #2 Reference Name Years Known Phone Relationship Address Reference #3 Reference Name Years Known Phone Relationship Address APPLICANT ATTESTATIONS All employment offers with The Village at Luther Square dba LIFE Northwestern Pennsylvania are contingent upon the candidate passing a Physical Examination, Drug Screening Test, Criminal Background Examination and Mantoux (2-step TB Test). In consideration of my employment, I agree to abide by the rules and regulations of The Village at Luther Square dba LIFE Northwestern Pennsylvania, and I understand that these rules and regulations, and any personnel manual, DO NOT constitute a contract of employment. I further understand that no supervisor or representative of the employer has any authority to enter into any agreement for employment for a specified period of time or to make any agreement contrary to the forgoing. * I affirm that I have read and understand this application. That I have not withheld any information requested and that the statements I have made are true and correct. In the event of employment, I understand that false or misleading information given in my application or interview(s), may result in immediate discharge as willful misconduct. * I authorize any previous Employers, Educational Institutions, or individuals specified by me in this application to release any and all information regarding my employment or scholastic standing, together with any other information, personal or otherwise, that may or may not be contained on their records, and I hereby release said Employers, Educational Institutions, or Persons from liability for any damage or injury to me arising out of the release of such information. * I understand that I may be required to undergo physical examination(s) and/or drug testing(s) as a condition of employment. * I understand that my employment and compensation can be terminated with or without cause and without notice at any time at the option of the employer. * I understand the employer requires a notice of, 2 weeks for non-clinical positions and 4 weeks for any clinical or salaried position, if the employee decides to resign from their position. * Applicants Signature * Date Signed * APPLICATIONS KEPT ON FILE FOR 6 MONTHS Applicant must check all attestations before proceeding to final page. Review and Submit
