Employment Application 1 2 PERSONAL INFORMATION Applicants will receive consideration for employment without regard to race, color, national origin, creed or religion, sex, marital status, age, handicap or any other personal characteristics protected by federal, state or local laws. We encourage the employment of veterans of the United States Armed Forces and all other qualified applicants. The employer will not refuse to hire a disabled applicant who is capable of performing the essential requirements of the job with or without reasonable accommodations. You are not required to disclose information about physical or mental limitations that you believe will not interfere with your ability to do the job. On the other hand, if you want the employer to consider special arrangements to accommodate a physical or mental impairment, you may identify that impairment in the space provided and suggest the kind of accommodation you believe would be appropriate. Providing this information is strictly voluntary. If provided, it will be kept confidential. Refusal to provide this information will not subject applicants to adverse treatment. Applicants are kept on the file for a minimum of one year. You may update your application upon request. False statements or omission of requested information on this application form shall be considered sufficient cause for rejection during the hiring process. If false statements or omission are discovered after hire, they shall be considered sufficient cause for termination of employment. Applicants will be considered at the time of receipt If you wish to update your application or request additional consideration, you must contact the facility. Last*First*MiddleAddress*DatePhoneEmail What position are you applying for today?Are you authorized to work for wages in the United States?YesNoIf you answered "Yes" you will be required to present documentation showing your employment authorization and identity. Age is not used as hiring criteria unless required by law. If you are under 18, you may be required to prove your age for some jobs where state safety standards make restrictions. In some states, you may be required to present a work permit. Douglas Care Center, LLC has no mandatory retirement age. If you are eligible for Social Security benefits, Medicare or over 65, your wages and benefits from DCC could affect your government program benefits. We are proud to employ staff in their seventies and eighties.Referral SourceState Job ServiceAdCurrent Staff MemberWalk-inOtherPlease list referring employee nameNOTE: ALL PERSONS ARE SUBJECT TO A DRUG TEST PRIOR TO EMPLOYMENT Work DesiredType of work or position(s) desired:Full-timePart-timeTemporaryDates you can start permanent employment:Dates of temporary employment availability:Scheduling: Normal office hours are maintained Monday thru Friday in our Business Office with the exception of some weekend, evening, and night shift work. Every nursing facility must be staffed 7 days a week, 24 hours a day. Work schedules are varied and require flexibility. Based on our staffing needs, we may not always be able to accommodate your scheduling preferences. Therefore, please consider carefully all of your personal time/commitments before responding to the following questions.Shift(s) You Can Work Days Evenings Nights Any 2nd ChoiceNoneDaysEveningsNightsCan you rotate shifts?YesNoIndicate all the days you would be able to work:SundayMondayTuesdayWednesdayThursdayFridaySaturdayWork Experience/ReferencesHave you ever worked for DCC before?YesNoIf yes, where and dates worked?Position held:Immediate Supervisor:Reason for Leaving:List most recent employer first. Include military service if among last four jobs. You may list volunteer experience if you do not have paid work experience with four employees. Write "V" in the salary column.EMPLOYMENT #1EmployerAddressPhoneDates of EmploymentEnter a start date and an end date.Job TitleSupervisor's Name/Job TitlePrimary Job DutiesFinal Salary $Reason for LeavingMay we contact for a reference?YesNoIf not, please explain:EMPLOYMENT #2PhoneAddressDates of EmploymentPlease enter the start date and the end date.Job TitleSupervisor's Name/Job TitlePrimary Job DutiesFinal Salary $Reason for LeavingMay we contact for a reference?YesNoIf not, please explain:EMPLOYMENT #3PhoneAddressDates of EmploymentEnter a start date and an end date.Job TitleSupervisor's Name/Job TitlePrimary Job DutiesFinal Salary $Reason for leavingMay we contact for a reference?YesNoIf not, please explain:EMPLOYMENT #4PhoneAddressDates employedEnter a start date and an end date.Job TitleSupervisor's Name/Job TitlePrimary Job DutiesFinal Salary $Reason for leavingMay we contact for a reference?YesNoIf not, please explain:Lisa any other references we may contact (We will not employ relatives in a position where a direct supervisory relationship will exist)Explain any circumstances(s) that may affect reference received:LICENSURELICENSED PRACTICAL NURSEState Number/Expiration DateREGISTERED NURSEState Number/Expiration DateCERTIFIED NURSES ASSISTANTState Number/Expiration DateAdministratorState Number/Expiration DateRPTState Number/Expiration DateOtherIf you don't have a license, have you applied?YesNoIf exam is required, give schedule date:If not licensed in this state, have you applied for reciprocity?YesNoAre there any current restrictions, or have there been any restrictions in the past placed on any license listed above?YesNoIf yes, please explain:Are there any current complaints, or have there been any complaints in the past placed on any license listed above?YesNoIf yes, please explain:SKILLSPlease check ALL items in which you have training and/or experience Supervision of Employees Teaching Accounts Payable Accounts Receivable Payroll Full Charge Bookkeeping Financial Statements Cost Reporting Auditing Taxes Budgeting Shorthand/Speedwriting Diction Equipment 10 Key Adding Machines Calculator Key Punch Machines Switchboard Copy Machines Clinical Skills Blood Pressure T.P.R. Feeding Disabled Patients Transfer Techniques Alignment & Positioning Range of Motion B & B Training Catheterization Medicare/Medicaid Reimbursement Medical Records Insurance Billing Typing Typing WPMLong Term Care/Rehabilitation Nursing Techniques Administration of Medicine Isolation Techniques Sterile Techniques Reality Orientation Therapeutic Activity Programs Use of P.T. in Long Term Care Use of O.T. in Long Term Care Charting Patient Care Plans Data Processing Word Processor Computers EDUCATIONSchool/Location and Type of DegreeRelevant CoursesSchool/Location and Type of DegreeRelevant CoursesSchool/Location and Type of DegreeRelevant CoursesOther Education (Seminars, Military, Schools, etc.)I have read all sections of this application and authorize verification of my statements. I understand that misrepresentation may be considered cause for rejection in the hiring process or termination of employment. I further understand my employment may be subject to a physical examination, drug screening, favorable references and documentation of my right to work in the U.S. if a bonafide job offer is made. In consideration of my employment, I agree to conform to the rules, procedures, and regulations of DCC. I understand that my employment and compensation can be terminated with or without cause, and or without notice, at any time, at the option of either the facility or myself I understand that no representative of DCC other than the Administrator/Board of Directors has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing. Signature and DateInterviewed by:Name/Job Title/DateInterviewed by:Name/Job Title/DateInterviewed by:Name/Job Title/DateResumeAccepted file types: pdf, doc, docx.Please attach your resume here.To prevent spam please enter: "1234"* This iframe contains the logic required to handle Ajax powered Gravity Forms.