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Date:
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Position:
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Name:
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SSN:
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Address:
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City/State/Zip:
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Home Phone:
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Message Phone:
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Are you currently employed?
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Are you at least 18 years old?
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Have you ever been an employee of Archie Hendricks Sr. Skilled Nursing Facility?
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If yes, when?
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Were you referred to Archie Hendricks Sr. Skilled Nursing Facility by one of our employees?
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If yes, whom?
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Which shift do you prefer?
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Would you like to work?
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Date Available:
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Salary Desired:
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Are you legally eligible for employment in the U.S.?
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If employed, can you provide proof of U.S Citizenship, or proof of your right to live and work in the U.S.?
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Are you registered with a federally recognized Indian Tribe?
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If yes, what Tribe?
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Proof of documents attached/available?
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If you are applying for a position that require driving please indicate if you have had traffic violations.
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If yes, please explain:
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Have you ever been convicted of a felony(s) or misdemeanor(s)?
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If yes, please explain:
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No application will be barred employment solely on the basis of conviction of a criminal offense. The nature of the offense, date, surrounding circumstances and relevance of the offense to the position, however, may be considered. Additionally, ARCHIE HENDRICKS SR. SKILLED NURSING FACILITY will comply with all state and federal regulations concerning employment of certified or licensed staff relating to conviction of felony or misdemeanor offeses.
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If hired, would you have a reliable means of transportation to and from work?
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Are you able to perform the essential functions of the job for which you are applying?
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If no, describe which functions can't be performed.
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Note: AHSSNF complies with the ADA and consider reasonable accommodation measures that may be necessary for applicants/employees to perform essential job functions.
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Professional Licenses and Certificates
Please list all professional licenses & certificates (i.e. RN, LPN, CNA, Caregiver). Please note: All certificates must be provided at time of hire.
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License/Certificate Type:
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License Number:
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Expiration Date:
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CPR?
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First Aide?
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Fingerprint Clearance Card?
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Has your professional license ever been suspended or revoked?
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If yes, please explain:
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Training, Skills or Qualifications
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Please indicate skills and/or training that would enhance your qualifications:
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Education
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High School/GED:
Name/Years Completed/Degree Received After Graduation:
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Technical or Nursing School;
Name/Years Completed/Degree Received After Graduation:
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College or University:
Name/Years Completed/Degree Received After Graduation:
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Personal References
Please list three persons not related to you whom you have known for at least one year.
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Name/Occupation/Phone Number
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Employment
Please start with your most recent employer including military service for the last 10 years.
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May we contact your current employer?
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1. Company:
Phone Number:
Position:
Supervisor:
Duties:
Employment From: To:
Reason for Leaving:
Salary:
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2. Company: Phone Number: Position: Supervisor: Duties: Employment From: To: Reason for Leaving: Salary:
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3. Company: Phone Number: Position: Supervisor: Duties: Employment From: To: Reason for Leaving: Salary:
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4. Company: Phone Number: Position: Supervisor: Duties: Employment From: To: Reason for Leaving: Salary:
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Please Read Carefully and Sign Below
Archie Hendricks Sr. Nursing Facility is an equal opportunity emplyer, and selects individuals best matched for the job based upon job-related qualifications regardless of race, religion, color, creed, sexual orientation, national origin, age, disability, or any other status or characteristic protected by law.
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I certify that all statements contained in this application (including attachements, if any) are true to the best of my knowledge. If Archie Hendricks Sr. Nursing Facility, during it's investigation, or later if I am employed, discovers that statements have been omitted or are false or misleading,
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I understand that I may receive no further consideration for employment and that this may be grounds for dismissal.
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My signature below authorizes all current and prior employers, educational institutions and branches of the United States Armed Services, whether listed above or not, to furnish Archie Hendricks Sr. Nursing Facility with complete information concerning my employment, academic transcripts, and service records.
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The information requested may include inquiries regarding my work habits, other related activities, abilities, character, and the cause of my separation.
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I hereby authorize Archie Hendricks Sr. Nursing Facility to investigate my personal history and to obtain from my previous employers or personal references any information they have concerning me.
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I am hereby informed that as part of the employment procedure an investigative consumer report may be made whereby information is obtained through mail, telephone and personal interviews with previous employers, personal references, friends and/or others with whom I am acquainted or have been employed.
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This inquiry if made may include information as to my character, general reputation, personal characteristics and work habits.
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I understand that Archie Hendricks Sr. Nursing Facility may be requesting information concerning my motor vehicle operation history and
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criminal history from various states, private and insurance sources along with other public records available.
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Further, I understand I have the right to make a written request within reasonable time to receive additional detailed information about the nature and scope of any investigation that is made.
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I am fully aware and understand that my employment may be subject to meeting Archie Hendricks Sr. Nursing Facility standards with respect to an employment screening and/or an employment substance abuse test.
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If employed, I understand that such employment is at will, and as such is for no specific duration and may be terminated at any time with or without cause.
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I release each of the above references and Archie Hendricks Sr. Nursing Facility and authorized representatives from any liability for damages, which might result from the furnishing of or the use of any of this information.
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I understand that completion of this application does not indicate that there are any positions open and does not obligate this company to hire me or offer me a job.
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In consideration of my employment, I agree to conform to the rules and regulations of Archie Hendricks Sr. Nursing Facility.
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Applicant's Signature (type name):
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Date:
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Archie Hendricks Sr. Skilled Nursing Facility is an equal opportunity employer. No discrimination is made against any individual in any phase of employment in accordance with local, state and federal laws.
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Name:
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Email Address:
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