Private Nursing Service, Inc. Application for Employment 4

PRIVATE NURSING SERVICE, INC. APPLICATION FOR EMPLOYMENT {4}

PERSONAL INFORMATION SHEET Please read carefully, write dearly, answer all questions

LAST NAME / FIRST / MIDDLE / SOCIAL SECURITY #
STREET ADDRESS / CITY / STATE / ZIP CODE
HOME TELEPHONE NUMBER / CONTACT MESSAGE TELEPHONE NUMBER
IF YOU HAVE BEEN EMPLOYED UNDER A LAST NAME OTHER THAN THE ONE YOU ARE USING CURRENTLY,
PLEASE LIST THOSE NAMES ______
HAVE YOU EVER BEEN ON THE EMPLOYEE DISQUALIFICATION LIST UNDER ANY NAME?
YES _____ NO _____
WERE YOU EVER EMPLOYED HERE BEFORE? YES ______NO ______
JOB TITLE ______DATES ______
HOW WERE YOU REFERRED TO US FOR EMPLOYMENT? ______
LIST RELATIVES EMPLOYED HERE ______
ARE YOU LEGALLY ABLE TO WORK IN THE UNITED STATES? YES ______NO ______
(PROOF REQUIRED)
HAVE YOU EVER BEEN CONVICTED OF A FELONY? YES ______NO ______
HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR? YES ______NO ______
HAVE YOU EVER BEEN CONVICTED, PLEAD GUILTY TO, OR NOIO CONTENDERE IN THIS STATE OR ANY
OTHER STATE TO ANY A OR B FELONY VIOLATIONS? YES ______NO ______
IF YES, PLEASE DESCRIBE CONVICTION AND GIVE DATE ______
JOB(S) APPLYING FOR ______
SHIFTS PREFERRED (PLEASE CIRCLE ALL APPLICABLE) DAY EVENING NIGHT
DATE AVAILABLE FOR WORK ______WAGE DESIRED ______

LICENSURE/REGISTRATION

INDICATE LICENSURE OR CERTIFICATION FOR ANY PROFESSIONAL, SKILL, OR TRADE (IF APPLICABLE)
OCCUPATION ______NUMBER ______STATE ______EXP. DATE ______
OCCUPATION ______NUMBER ______STATE ______EXP. DATE ______
IF YOU HAVE APPLIED FOR REGISTRATION/CERTIFICATION, PLEASE INDICATE DATE OF APPLICATION
______

PRIVATE NURSING SERVICE, INC. IS AN EQUAL OPPORTUNITY EMPLOYER AND WILL NOT DISCRIMINATE ON

THE BASIS OF DISABILITY, VETERAN STATUS, RACE, COLOR, CREED, RELIGION, NATIONAL ORIGIN, AGE, OR

SEX AS PROVIDED BY LAW.

OFFICE USE ONLY EDL CHECKED BY ______DATE ______

REVISED 01/01

U.S. MILITARY SERVICE RECORD {4}

HAVE YOU EVER BEEN A MEMBER OF THE U.S. MILITARY SERVICE? YES ______NO ______
DATE ENTERED ______DATE DISCHARGED ______RANK AT DISCHARGE ______
SPECIAL SKILLS, TRAINING, OR EXPERIENCE ACQUIRED ______
______

EDUCATION

NAME OF SECONDARY/HIGH SCHOOL ______
LOCATION ______YEARS COMPLETED ______
COURSE OF STUDY ______GRADUATE YES _____ NO _____
NAME OF COLLEGE ______YEARS COMPLETED ______
LOCATION ______COURSE OF STUDY ______
GRADUATE YES _____ NO _____ DEGREE ______
NAME OF COLLEGE ______YEARS COMPLETED ______
LOCATION ______COURSE OF STUDY ______
GRADUATE YES _____ NO _____ DEGREE ______
NAME OF GRADUATE SCHOOL ______YEARS COMPLETED ______
LOCATION ______COURSE OF STUDY ______
GRADUATE YES _____ NO _____ DEGREE ______
NAME OF BUSINESS, TRADE,
OR VOCATIONAL SCHOOL ______YEARS COMPLETED ______
LOCATION ______COURSE OF STUDY ______
GRADUATE YES _____ NO _____ DEGREE ______

EMPLOYMENT HISTORY (LIST MOST RECENT POSITION FIRST)

NAME OF COMPANY/INSTITUTION ______
ADDRESS (CITY,STATE,ZIP CODE) ______
TELEPHONE ______JOB TITLE ______
FROM (MONTH & YEAR) ______TO (MONTH &YEAR) ______
JOB DUTIES ______
REASON FOR LEAVING ______
SUPERVISOR ______FINAL SALARY $______PER ______
EXPLANATION FOR GAP OF EMPLOYMENT IF MORE THAN THREE (3) MONTHS ______
______
NAME OF COMPANY/INSTITUTION ______
ADDRESS (CITY,STATE,ZIP CODE) ______
TELEPHONE ______JOB TITLE ______
FROM (MONTH & YEAR) ______TO (MONTH &YEAR) ______
JOB DUTIES ______
REASON FOR LEAVING ______
SUPERVISOR ______FINAL SALARY $______PER ______
EXPLANATION FOR GAP OF EMPLOYMENT IF MORE THAN THREE (3) MONTHS ______
______
NAME OF COMPANY/INSTITUTION ______
ADDRESS (CITY,STATE,ZIP CODE) ______
TELEPHONE ______JOB TITLE ______
FROM (MONTH & YEAR) ______TO (MONTH &YEAR) ______
JOB DUTIES ______
REASON FOR LEAVING ______
SUPERVISOR ______FINAL SALARY $______PER ______
EXPLANATION FOR GAP OF EMPLOYMENT IF MORE THAN THREE (3) MONTHS ______
______
LIST THREE REFERENCES (NOT RELATIVES)
NAME ______TELEPHONE ______
NAME ______TELEPHONE ______
NAME ______TELEPHONE ______

I CERTIFY THAT ALL INFORMATION IS ACCURATE AND COMPLETE AND UNDERSTAND THAT MIS-REPRESENTATION OR OMISSION OF FACTS MAY RESULT IN MY REMOVAL FROM CONSIDERATION FOR EMPLOYMENT OR DISMISSAL AFTER EMPLOYMENT. I AUTHORIZE THE ADMINISTRATION OF THIS INSTITUTION TO INVESTIGATE, WITHOUT LIABILITY, ALL STATEMENTS CONTAINED IN THIS APPLICATION AND HEREBY RELEASE SUCH PERSON, CORPORATION, OR OTHER ORGANIZATION FROM ANY AND ALL LIABILITY FOR PROVIDING SUCH INFORMATION. I ALSO AUTHORIZE FORMER EMPLOYERS AND REFERENCES, WITHOUT LIABILITY, TO MAKE FULL RESPONSE TO ANY INQUIRIES BY THE ADMINISTRATION OF THIS INSTITUTION IN CONNECTION WITH THIS APPLICATION FOR EMPLOYMENT. I UNDERSTAND THAT THIS APPLICATION IS NOT, NOR IS INTENDED TO BE A CONTRACT OF EMPLOYMENT. I AGREE TO CONDUCT MYSELF IN ACCORDANCE WITH THE POLICIES AND REGULATIONS OF THIS ORGANIZATION.

APPLICANT SIGNATURE ______DATE ______

FOR OFFICE USE ONLY: LICENSURE/REGISTRATION VERIFICATION
TYPE ______NUMBER ______STATE ______EXP DATE ______
STATUS ______NAME OF OFFICIAL WHO VERIFIED ______
SIGNATURE ______