Emerald Nursing & Rehab Application

Home Application

    EMERALD NURSING & REHAB

    EMPLOYMENT APPLICATION

    DIRECTIONS: Respond to ALL questions. If a particular question does not apply to you, or the position for which you are applying, write N/A In the appropriate blank. PLEASE PRINT CLEARLY. Incomplete applications will not be considered.

    EQUAL OPPORTUNITY EMPLOYER: Emerald Nursing & Rehab. will not discriminate against any employee or applicant for employment because of race, color, religion, sex, age, national origin, ancestry, citizenship status, disability, handicap or any other legally protected category. Any information received about the applicant will not be used for impermissible purposes.

     

    PERSONAL

    Name

     

     

    Last 4 Digits of Social Security No.

    Date of Application

    Address

    City

    State

    Zip Code

    E-mail Address

    Home Phone

    Alternate Phone

    Are employment records pertaining to you kept under any other name? If yes, give full name.
    YesNo

    If under 18 years of age, do you have a work permit?
    YesNo

    How did you hear of job opening?

    In case of emergency notify:

     

     

    POSITION DESIRED

    Position Applied for:

    (Be Specific)

    Date Available:

    Shift(s) Preferred: DayEveningNightAll

    Days Preferred: SunMonTuesWedThursFriSat

    Salary Expected

     

    Full-TimePart-TimePRN/per diemTemporary

    Are you willing to work weekends? YesNo

     

    LICENSE OR CERTIFICATION

    Type

    State

    Date Received

    Last Renewal

    Certificate Number
    ExaminationReciprocity

    Type

    State

    Date Received

    Last Renewal

    Certificate Number
    ExaminationReciprocity

    Type

    State

    Date Received

    Last Renewal

    Certificate Number
    ExaminationReciprocity

     

    EDUCATION

    Are you attending school now? YesNo

    Course of Study

    Circle last year of school completed:
    1 2 3 4 5 6 7 8 9 10 11 12

    College:
    1 2 3 4 5 6 7 8

    Nursing:
    1 2 3 4

    Business or Trade:
    1 2 3 4

    High School

    City/State

    Degree

    Grade Point Average

    Graduate
    YesNo

    College or Nursing

    City/State

    Degree

    Grade Point Average

    Graduate
    YesNo

    Business or Trade

    City/State

    Degree

    Grade Point Average

    Graduate
    YesNo

     
     

    Please check the box that best describes your attendance at your most recent place of employment.

    ExcellentGoodAverage

    Position Title

    Approx. Dates

     

    Supervisor

    Reason for Leaving

     

    WORK HISTORY (This section of the application must be completed even if a resume is submitted.)

    Please Ilst the name(s) of present and previous employers in order, beginning with the most recent employer. Include periods of Uniformed Service, self-employment and unemployment. Attach additional sheets if necessary.

    Position Title

    From

    to

    Position Responsibilities

    Reason for Leaving

    Name and Title of Immediate Supervisor and Starting and Ending Salary

    $

    Per

    Employer & Phone

    Address Including Zip Code

     

    Position Title

    From

    to

    Position Responsibilities

    Reason for Leaving

    Name and Title of Immediate Supervisor and Starting and Ending Salary

    $

    Per

    Employer & Phone

    Address Including Zip Code

     

    Position Title

    From

    to

    Position Responsibilities

    Reason for Leaving

    Name and Title of Immediate Supervisor and Starting and Ending Salary

    $

    Per

    Employer & Phone

    Address Including Zip Code

     

    Position Title

    From

    to

    Position Responsibilities

    Reason for Leaving

    Name and Title of Immediate Supervisor and Starting and Ending Salary

    $

    Per

    Employer & Phone

    Address Including Zip Code

    May we contact your present employer. NoYes

    Signature (Incomplete applications will not be considered)

    NOTICE: I understand that this employment application and any other Company documents are not contracts of employment, express or implied, and that if hired, t may voluntarily leave employment, or may be terminated by the Company at any time and for any or no reason, with or without cause. I understand that any oral or written statements to the contrary are hereby expressly disavowed and will not be relied upon by me. I give the Company and its agents permission to enter the information "rrs`';d0 ^n th,c application into electronic information systems used by the Company. The information given by me is certified to be true and complete for all practical purposes and it may be verified by Emerald Nursing & Rehab Should a position be offered and later it is found that the information is untrue, incomplete or misrepresented, I understand and agree that 'Emerald Columbus ceder. is relieved of all commitments, financial or otherwise, pertinent to employment, and that I am subject to immediate discharge without recourse. I also understand that I may be offered employment ...:011ditioned on my successfully passing criminal and/or other background checks and/or drug test and/or physical exam to the satisfaction of the Company.

    Are you authorized (i.e. Social Security card or work visa) to work in the
    United States?   NoYes

    If yes, can you submit verification of your legal right to work in the United States if offered a position?   NoYes

    Signature of Applicant

    Date

     

    EMERALD NURSING & REHAB is required by law to ask the following questions and may be required by law to report the answers to governmental agencies responsible for supervising health care, nursing home, home care and/or hospice care activity:

    1. Have you ever been convicted and/or been found guilty by a court of competent jurisdiction or a state agency of abusing, neglecting or rnistreating residents or of misappropriating resident property in this state or in any other state? If so, please describe the offense, the date and place of the conviction, and the underlying circumstances or other information to help us evaluate your current fitness for employrnent.    NoYes

    Explain

    2. Have you ever been convicted of a felony? If so, please describe the offense, the date of the conviction and the underlying circumstances or other inforrnation to help us evaluate your current fitness for employment.    NoYes

    Explain

    3. Have you ever been convicted of (1) cruelty to persons or (2) assault of a victim 60 years of age or side/it so, please describe the offense, the date of the conviction and the underlying circumstances or other information to help us evaluate your current fitness for employment.    NoYes

    Explain

    4. Have you ever been sanctioned by a health care licensing agency in this or any other state, or in any other United States or foreign jurisdiction? If so, please identify the nature and date of the action, the licensing agency involved and the underlying circumstances or other information to help us evaluate your current fitness for employment.    NoYes

    Explain

    "I hereby certify that have not been convicted and/or found guilty of resident or patient abuse, neglect or mistreatment, or of rnisappropriation of resident or patient property in this state or in any state, and that I am not listed in any resident or patient abuse registry in this state or in any other state. I understand that any offer of employment that is extended to me by Emer. Care cen. is conditional upon the verification of this information with the state patient abuse registry ana tn. a listing in such registry or the registry of any other state may act as an automatic withdrawal of any such offer of employment"

    i further understand that if I'm applying fora licensed or certified position, any offer of employment by
    is conditional upon verification of my license or certification with the appropriate sta. agency. In the event that I have not yet been so licensed or certified and in the event that I am offered employment witherner. Care Center, I agree to undertake the required training and competency certification requirements immediately upon commei.ing employment"

    Signature of Applicant

    Date

    Print Name as Written Above

    PLEASE SEE REVERSE SIDE OF THIS PAGE FOR IMPORTANT INFORMATION

     

    INVESTIGATION INFORMATION RELEASE AUTHORIZATION

    I understand that EMERALD CARE CENTER requires a thorough pre-employment background investigation. This investigation is limited to only that information required to determine fitness for employment and may include, but is not limited to: employment history verification, job performance, disciplinary record, financial/credit history and a criminal background investigation. By signing this document, I agree to hold harmless any previous employer, agent of that corporation, or any individual or organization providing information pursuant to this Authorization.

    Date

    Applicant Signature

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