Careers |

Date*

Name

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Position applying for*

Have you submitted an application or been employed here before?*

Yes
No

If yes give date(s) and position(s)

Are you legally eligible for employment in this country?*

Yes
No

Days/hours available for work*

If applying for a Licensed Nurse or Nursing Assistant position shift(s) available for work

Employment desired*

Full-Time
Part-Time
On-Call

If hired, on what date can you start working?*

If hired, are you willing to submit to and pass a controlled substance test?*

Yes
No

If hired, are you willing to submit to and pass a criminal background check?*

Yes
No

Are you able to perform the essential functions of the job for which you are applying, either with/without reasonable accommodation?*

Yes
No

If no, describe functions that cannot be performed

Are you over the age of 18?*

Yes
No

May we contact your present employer?*

Yes
No

Please list the name and telephone number of three business/work references who are not related to you. If not applicable, list three school or personal references who are not related to you.*

I certify that all answers and statements on this employment questionnaire are true and complete to the best of my knowledge. I understand that, should this application contain any false or misleading information, my application may be rejected or my employment with this company terminated. I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, or federal law.

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Sharon Care Center