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Employment Application

Personal & General History
Have you ever been arrested, plead guilty to and/or convicted by any court, including a court of military justice?
Check year Completed:
Check Year Completed:
Personal Reference Information (no relatives please)
Reference 1:
Reference 2:

Reference 3:

Employment History

Company #2:

Company #3:

  • If hired you will be required to submit proof of authorization to work in the United States.

  • Hire is subject to verification that employee's age meets legal requirements.

  • The shift, working hours or duties may be changed from time to time due to changes in management, policy or procedure.

  • Proof of license for Licensed Nurses is required by this facility.

  • A Criminal Records check will be made in accordance with Senate Bill 160.

I certify that answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
This application for employment shall be considered active for a period of time not to exceed 12 months. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.
If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.
In the event of employment, I understand that false or misleading information on my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

I have read and understand the above and agree to all items stated:
Applicant Survey

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