Royal Oak Nursing Center
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Employment Application
Last name:
First name:
Middle name:
Today's Date:
Present Address:
Apt #:
City:
State:
Zip Code:
Phone Number(with area code):
Alternative Number(with area code):
Social Security Number:
Are you eligible to work in the United States:
Yes
No
Have you ever worked for a hospital, nursing home, homecare or any medical related field:
Yes
No
Have you ever been convicted of a crime(excluding traffic vilolations:
Yes
No
If yes, please explain:
Date:
City and State:
Do you have any realitives that work for Royal Oak Nursing Center:
What are their names:
Do you have any friends that work at Royal Oak Nursing Center:
What are their names:
Positions on which you are applying:
RN
LPN
CNA
Dietary Cook
Dietary Aid
Dishwasher
Social Worker
Laundry
Maintenance
Therapy OT
Therapy PT
Therapy Speech
Bookeeper
Activities
Medical Records
Clerical
Housekeeping
Central Supply
Wages Expected:
per hour
per week
per month
Do you want:
Full Time Employment
Part Time Employment
If Full Time, which shift would you perfer:
Morning
Evening
Night
If Part Time, how many hours per week:
What shifts are you available for:
Morning
Evening
Night
Which days of the week are you available to work(Please check the days you can work):
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
After what date are you available to work:
Month
Day
Year
Have you read the job description(s) for the job(s) in which you are applying for:
Yes
No
Are you able to perform all tasks described:
Yes
No; If not explain:
If certified or licensed by any State in the healthcare field, please give: License number:
License State:
Education: Check the highest grade level completed:
6
7
8
9
10
11
12
Associates Degree
Bachelor's Degree
Master's Degree
Name of High School:
Dates attended:
Degree type:
Name of College or University:
Dates attended:
Degree type:
Name of Technical School:
Dates attended:
Degree type:
Account fo all periods of employment and unemployment, starting with the most current
Date employment started and ended:
Employer:
Employer Address:
Duties:
Why did you leave:
Date employment started and ended:
Employer:
Employer Address:
Duties:
Why did you leave:
Date employment started and ended:
Employer:
Employer Address:
Duties:
Why did you leave:
Date employment started and ended:
Employer:
Employer Address:
Duties:
Why did you leave:
Date employment started and ended:
Employer:
Employer Address:
Duties:
Why did you leave:
Date employment started and ended:
Employer:
Employer Address:
Duties:
Why did you leave:
Date employment started and ended:
Employer:
Employer Address:
Duties:
Why did you leave:
May we contact the employers above:
Yes
No
If not, which may we contact:
Military Service:
Branch of Service:
Entered:
Discharge:
Rank:
Type of Discharge
Branch of Service:
Entered:
Discharge:
Rank:
Type of Discharge
Branch of Service:
Entered:
Discharge:
Rank:
Type of Discharge
I hereby verify that if I become employed, I understand that as a continuing condition of my employment, I will:
1. Maintain a positive and harmonious relationship with patients visitors and staff:
Yes
No
2. Appear for duty as schedualed or at least secure a replacement in the event of unforeseen circumstances:
Yes
No
3. Be a team member, rendering help to a fellow staff in other departments as needed:
Yes
No