Application For Employment

(Check box next to affiliate you are applying to)
Fort Hudson Nursing Center
Fort Hudson Home Care

Today's Date:

Social Security # XXX-XX -

Last Name:
First Name:
Middle:

(Other Name Known By):

Street Address:
City:
State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip:

E-mail Address:

Telephone:

Cell Phone:

Are you 18 years of age or older? Yes No

If hired, can you provide written evidence of authorization to work in the U.S.? Yes No

Have you been convicted of a crime? (If Yes, See Below) Yes No

Have you had a prior finding of patient or resident abuse? (If Yes, See Below) Yes No

If you answered YES to any of the above 2 questions please identify what you were convicted of, your age at the time, the county and state where the conviction was imposed and the date on which it was imposed. In addition, please describe the events underlying the conviction, any sentence imposed and your rehabilitation since the conviction: (Conviction will not necessarily disqualify an applicant from employment )

Employment

Position Type Applying For: Full time Part time Per Diem

Shift Preferred: Day Evening (2PM to 10 PM) Night (10 PM to 6 AM)

Do You Have Any Relatives Who Are Employed By This Organization?
Yes No   Specify:

Do You Have Any Friends Who Are Employed By This Organization?
Yes No   Specify:

Have you ever applied for employment at any Fort Hudson affiliate?
Yes No   If so, provide date(s):

Have you ever worked at any Fort Hudson affiliate?
Yes No   If so, provide date(s):

Reason For Leaving?

Please list professional license or certification number, if applicable:
RN# LPN# C.N.A# PCA#

U.S. MILITARY SERVICE

Branch of Service:

From: to

Rank and Type of Service:

Training/Experience Received:

EMPLOYMENT RECORD

(Begin with most recent position)

Company Name and Contact Info.

Name: Phone:

Address:

Job Title:

Dates Employed: Start End  

Reason for Leaving:

Explain Any Period Between Jobs:

Company Name and Contact Info.

Name: Phone:

Address:

Job Title:

Dates Employed: Start End  

Reason for Leaving:

Explain Any Period Between Jobs:

APPLICANT'S STATEMENT

• I certify that the information provided in and incorporated by reference into this application and all other information I provide during the hiring process is true and complete and I understand that any misrepresentation or omission may be justification for rejection of my application or cause for terminating my employment at any time.
• I also understand that any offer of employment or continuance of employment will be based upon satisfactory references and my ability to document legal citizenship or the right to accept employment within the U.S.
• I hereby release from all liability or damages, those persons, agencies, and organizations who may furnish information in connection with my inquiry for employment.
• I authorize EMPLOYER to conduct reference checks as part of its evaluation of my application for employment.
• I understand that if I am offered employment, it will be conditioned on my cooperating with and satisfactorily completing a fingerprint-based search of State Division of Criminal Justice Criminal History records, as well as a pre-employment drug screen and medical examination relative to the job for which I am being considered.
• I understand that I may also be required to undergo subsequent physical examinations after I am hired.

Please type your name to agree and certify that the above statements are accurate:

CONFIDENTIAL REFERENCE REQUEST

Name - (include Maiden name )

Applicant's Consent: I hereby authorize you to provide any information you may have regarding my performance and character.

Type you name to agree: