ONLINE JOB APPLICATION Name* First Middle Last Desired PositionDate Date Format: MM slash DD slash YYYY Personal InformationSocial Security NumberEmail Address Street Address City State / Province / Region ZIP / Postal Code PhoneAlternate PhoneOther Name(s) under which employedEmployment DesiredFirst Choice PositionFirst Choice ShiftFirst Choice SalarySecond Choice PositionSecond Choice ShiftSecond Choice SalaryHow Did You Hear About This Opening?Have You Ever Been Employed With Elizabeth Scott Community, Inc.?YesNoFrom MM DD YYYY Through MM DD YYYY Will You Accept Employment Of: Full Time Part Time Temporary Contingent If Under 18 Yrs. Of Age, Do You Have A Work Permit?YesNoDate Available MM DD YYYY Education/ TrainingHigh SchoolSchool NameSchool AddressCourses TakenDid You Graduate?YesNoDiploma, Degree, or Certificate ReceivedCollegeSchool NameSchool AddressCourses TakenDid You Graduate?YesNoDiploma, Degree, or Certificate ReceivedSpecialized TrainingSchool NameSchool AddressCourses TakenDid You Graduate?YesNoIf Yes, Date? MM DD YYYY Diploma, Degree, or Certificate ReceivedOther Classes/ TrainingExtracurricular Activities While in SchoolProfessional Organization Membership, Honors received, Volunteer or Community Service or other qualifications you have that you feel are related to the position for which you are applying:Professional Licenses And/Or CertificationsTypeOrganization or State IssuedDate Issued MM DD YYYY NumberTypeOrganization or State IssuedDate Issued MM DD YYYY NumberTypeOrganization or State IssuedDate Issued MM DD YYYY NumberEmployment HistoryList current (or most recent) employer first and all others in reverse chronological order.Employer #1Company NameEmployed FromEmployed ToAddress Street Address City State / Province / Region ZIP / Postal Code PhoneStarting SalaryEnding SalaryPosition TitleImmediate Supervisor's Name and TitleJob Description & ResponsiblitiesMay we contact for reference?YesNoReason For Leaving:Employer #2Company NameEmployed FromEmployed ToAddress Street Address City State / Province / Region ZIP / Postal Code PhoneStarting SalaryEnding SalaryPosition TitleImmediate Supervisor's Name and TitleJob Description & ResponsiblitiesMay we contact for reference?YesNoReason For Leaving:Employer #3Company NameEmployed FromEmployed ToAddress Street Address City State / Province / Region ZIP / Postal Code PhoneStarting SalaryEnding SalaryPosition TitleImmediate Supervisor's Name and TitleJob Description & ResponsiblitiesMay we contact for reference?YesNoReason For Leaving:Employer #4Company NameEmployed FromEmployed ToAddress Street Address City State / Province / Region ZIP / Postal Code PhoneStarting SalaryEnding SalaryPosition TitleImmediate Supervisor's Name and TitleJob Description & ResponsiblitiesMay we contact for reference?YesNoReason For Leaving:Employer #5Company NameEmployed FromEmployed ToAddress Street Address City State / Province / Region ZIP / Postal Code PhoneStarting SalaryEnding SalaryPosition TitleImmediate Supervisor's Name and TitleJob Description & ResponsiblitiesMay we contact for reference?YesNoReason For Leaving:Have you ever been convicted of an offense or otherwise found guilty of an offense that would preclude employment in a nursing facility?YesNoIf so, for what, when and where?Conviction of a crime offense will not nessarily preclude your employment. Use this space to give us further information that may assist us in placing you.List Three Personal References (Not Relatives)Name And RelationshipTitleCompany & AddressTelephoneName And RelationshipTitleCompany & AddressTelephoneName And RelationshipTitleCompany & AddressTelephoneAvailability InformationPlease indicate in a brief summary the days and hours you are available for work. To be discussed in more detail during the interviewing process.Primary position desiredWill you accept another position?YesNoIf so, what?WeekendsYesNoHolidaysYesNoRotating ShiftsYesNoOn CallYesNoDo you limit your annual earnings due to Social Security or other reasons?YesNoIf yes, please state what is the maximum amount you wish to earnIn the event of a staffing emergency, department heads or administrator may require an employee to temporarily work shifts other than what they were hired for. Are you able to comply with this condition?YesNoHow did you hear about us to fill out this application?*Google SearchIndeedFacebookInstagramWord of MouthDrove ByCheck this box to confirm you job application* Confirm Application CAPTCHAThis institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination. I voluntarily give The Elizabeth Scott Community the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination, and such future physical examination, and such future physical examinations may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination (to include drug screen), which relates to the essential duties that I would be required to perform. I understand that all potential Elizabeth Scott Community employees must successfully complete a background check (to include finger printing) and physical examination (to include drug testing). I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment. This job application will be kept active on file for 90 days This iframe contains the logic required to handle Ajax powered Gravity Forms.
