Employment Application - Denham Springs, LA - Harvest Manor Healthcare and Rehabilitation

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General Information

Name:*

First Middle Last

Current Address:*

Street Address Address Line 2 City State ZIP Code

Home Phone:*

Business Phone:

Cell Phone:

Email:*

Position Applying For:*

Are you seeking:*

Full Time

Part Time

PRN

Shift Availability:*

Day

Evening

Night

Salary/Wage Expected:*

Date Available:

How were you referred to us?

Are you 18 years of age or older?*

Yes

No

Are you currently employed?*

Yes

No

If so, may we contact your current employer?

Yes

No

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

Are you legally able to work for any employer in the United States under the immigration laws of the United States?*

Yes

No

Have you even been convicted of or plead guilty to a felony?*

Yes

No

(A conviction record will not necessarily disqualify you from employment.)

If yes, please provide details:*

Have you ever been found guilty by a court of law of abusing, neglecting, mistreating, or misappropriating the property of an individual in a healthcare setting?*

Yes

No

(A conviction record will not necessarily disqualify you from employment.)

If yes, please provide details:*

Are you or have you ever been excluded from participation in the federal health care programs (for example, Medicare and Medicaid)?*

Yes

No

(A conviction record will not necessarily disqualify you from employment.)

If yes, please provide details:*

Have you ever been employed with Harvest Manor Healthcare and Rehabilitation?*

Yes

No

If yes, when?

Do you have any relatives employed at Harvest Manor Healthcare and Rehabilitation?*

Yes

No

Company policy restricts close relatives working in a reporting relationship.

If yes, please give their names:*

Registry, certification, or professional license 1: NUMBER

Registry, certification, or professional license 1: STATE

Registry, certification, or professional license 2: NUMBER

Registry, certification, or professional license 2: STATE

Registry, certification, or professional license 3: NUMBER

Registry, certification, or professional license 3: STATE

Have you ever had your professional license or certification suspended, revoked, or restricted?*

Yes

No

If yes, please provide details:

Work History

List the three most recent employers. Begin with most recent employer.

Company #1 Name:*

Phone:*

Job Title:*

Supervisor's Name:*

Address:*

Street Address City State

Start Date:*

End Date:*

Salary/Wage:

Describe your duties:*

Reason for Leaving:*

Eligible for rehire?*

Yes

No

Company #2 Name:

Phone:

Job Title:

Supervisor's Name:

Address:

Street Address City State

Start Date:

End Date:

Salary/Wage:

Describe your duties:

Reason for Leaving:

Eligible for rehire?

Yes

No

Company #3 Name:

Phone:

Job Title:

Supervisor's Name:

Address:

Street Address City State

Start Date:

End Date:

Salary/Wage:

Describe your duties:

Reason for Leaving:

Eligible for rehire?

Yes

No

Skills and Affiliations

Describe any previous work history or particular job responsibilities listed in your Employment History that you believe are important or should be considered. Include any additional information about your qualifications or experience you feel may be relevant to the job for which you are applying.

List any professional affiliations or accreditations that have a direct bearing upon your qualifications for the job for which you are applying.

Professional References

Please list three personal references, other than family members.

Reference 1 - Name:*

First Last

Phone:*

Address:*

City State

Reference 2 - Name:*

First Last

Phone:*

Address:*

City State

Reference 3 - Name:*

First Last

Phone:*

Address:*

City State

Applicant Must Read and Sign Below:

I certify that the answers I gave in this application and in any interviews are true and complete to the best of my knowledge.

I authorize investigation of all statements in this application and authorize my former employers, government agencies, schools, and personal references to provide any information they have regarding me. I release all employers, government agencies, schools, and personal references from any liability for providing information concerning me. If the results of this investigation do not meet the required standards for employment, I understand that an offer of employment may not be extended, may be revoked, or that my employment may be terminated.

I understand that this application is not a contract of employment. I understand that if I give false or misleading information on my application or in any part of the employment process, I may be fired. I agree to follow the Company’s rules and regulations. I understand that employment is at-will, meaning that either I or the company may terminate the employment relationship at any time for any reason not expressly prohibited by law. No one except a managing member of the company is authorized to change this at-will status, and any change must be done in writing and signed.

I understand that the Company may provide other future employers with reference information concerning my performance during employment and the reason for ending my employment. I consent to the release of this information.

I agree to inform the company if I obtain any other employment while working for the company, if I am hired here.

I acknowledge that I have read and understand these statements.

Electronic Signature:*

First Last

General Information

Education

Work History

Skills and Affiliations

Professional References