| Background Information |
| Last Name |
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| Middle Name |
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| First Name |
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| Previous Last Name |
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| Present Address |
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| City |
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| State |
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| Zip Code |
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| Phone Number |
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| Alternate Phone Number |
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| Social Security Number |
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| Are you at least 18 years of age? |
yes no |
| Do you have a legal right to work in the US? |
yes no |
| Do you have friends or relatives in our employ? |
yes no |
| If yes, name: |
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| Relationship |
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| Where employed? |
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| In what role? |
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| Felician Village? |
yes no |
| When? From: |
to |
| In what role? |
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| Position Information |
| Position Applying For |
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| I can work: |
FT |
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PT - If PT, how many hours per week? |
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On Call |
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Temporary - From to |
| What hours are you available to work? |
to |
| Salary Requirements |
$ |
| Date Available |
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| Education |
| Name of High School |
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| Address |
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| City |
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| State |
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| Last Grade Completed |
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| Degree/Course |
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| Name of College, University or Technical School |
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| Address |
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| City |
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| State |
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| Degree/Course |
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| Early Childhood Education |
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| Address |
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| City |
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| State |
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| Degree/Course |
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| Honors Received |
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| Student Activities, Internships, Offices Held, etc. |
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| Professional Affiliations |
| Type of certification, registration or license |
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| Certification Registration Number |
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| State |
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| Expiration Date |
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| Are you currently certified in CPR? |
yes no |
| Military Record |
| Military service |
yes no |
| Branch of service |
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| Rank at discharge |
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| Please describe any job related training you have received |
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| Clerical Skills |
| Current typing speed |
words per minute |
| Type of computer/word processing systems you are familiar with |
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| Other office machines you can operate |
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| Other office skills |
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| Previous Employment Record |
| Current or more recent employer's name |
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| Telephone |
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| Address |
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| City |
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| State |
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| Zip |
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| Department |
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| Supervisor's Name and Title |
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| Dates Worked From |
to |
| Total Time Worked |
Years Months |
| Earnings |
Start Final |
| Job Title |
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| Duties Performed |
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| reason for leaving |
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| may we contact your current employer? |
yes no |
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| Employer's Name |
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| Telephone |
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| Address |
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| City |
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| State |
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| Zip |
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| Department |
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| Supervisor's Name and Title |
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| Dates Worked From |
to |
| Total Time Worked |
Years Months |
| Earnings |
Start Final |
| Job Title |
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| Duties Performed |
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| Reason for Leaving |
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| Employer's Name |
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| Telephone |
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| Address |
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| City |
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| State |
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| Zip |
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| Department |
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| Supervisor's Name and Title |
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| Dates Worked From |
to |
| Total Time Worked |
Years Months |
| Earnings |
Start Final |
| Job Title |
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| Duties Performed |
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| Reason for Leaving |
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| Other skills, qualifications or experiences which you believe may be related to the job for which you are applying: |
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| Have you been convicted of any offense other than a minor traffic violation? |
Yes No |
| If yes, list dates and nature of offense |
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| Are you the subject of any pending charges in a court of law? |
Yes No |
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I HERBY CERTIFY that the answers given by me to the above questions and statements are true and correct and hereby authorize you to contact references, past or present employers, persons, schools, law enforcement agencies and any others sources of information that may be relevant to my application for employment. It is understood and agreed that any misrepresentation, false statement or omissions by me in this application will be sufficient reason for rejection of my application or for dismissal at any time during my employment, without liability to this facility. I have read, understand, and agree to the above statement.
I further understand that no representative of the facility has the authority to enter into any agreement for employment for any specified period of time and that this facility is not guaranteeing employment for anyone. No employment contract is created by virtue of my being hired by this facility. I have read, understand, and agree to the above statement.
If employed, I agree to abide by all of the work and safety rules of the facility. I understand that this facility is committed to maintaining a drug-free workplace. I am aware that the facility may require a drug test as a part of the hiring process. Also, if employed, I realize that the facility may conduct random drug testing and/or reasonable suspicion testing of its employees. I have read, understand, and agree to the above statement.
I understand that this application will remain on file for 90 days for consideration. After 90 days if I am still interested in a position with this facility, it will be necessary for me to complete a new application form. |
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