Apply Online | River Chase Village - Retirement Home & Residential Care Community

Position Applied For *

Name *

First

Middle

Last

Phone *

Email *

Address *

City *

State *

Zip *

Previous Address

If you have lived at the above address for less than 12 months.

Previous City

If you have lived at the above address for less than 12 months.

Previous State

If you have lived at the above address for less than 12 months.

Previous Zip

If you have lived at the above address for less than 12 months.

Are you 18 or older? *

Yes
No

Are you either a U.S. citizen or legally authorized to work in the United States? *

Yes
No

Proof of citizenship or right to work status will be required at time of hire.

Do you have adequate means of transportation to get to work on time each day? *

Yes, and on short notice
Yes, but not on short notice
No

Did you review the job description for the position for which you are applying? *

Yes
No

Do you meet the qualifications and have the ability to perform the essential job functions of this job? *

Yes
No

If no, please explain what qualifications you do not have.

Have you ever been convicted of or pled guilty to any criminal offense? *

Yes
No

Have you ever been confined (jailed) for any criminal conviction? *

Yes
No

Are you presently being charged with any criminal offense? *

Yes
No

Criminal Record Explanation

If your response to any of the 3 preceding questions was “YES”, give dates, places & nature of each such conviction or pending charge. (The existence of a conviction or pending charge will not necessarily preclude you from employment, the nature of the crime and its relationship to the position applied for, the degree of rehabilitation of the applicant and the time elapsed since the crime or release from confinement will all be considered.

COVID Vaccination Compliance *

Vaccinated (must supply vaccination card)
Not Vaccinated, will get vaccinated within the first two weeks of employment
Not Vaccinated, will apply for exemption within the first two weeks of employment
Not Vaccinated, unwilling to get vaccinated

Date You Can Begin Work

Shifts You Can Work

1st (6:45AM – 3:15PM)
2nd (2:45PM – 11:15PM)
3rd (10:45PM – 7:15AM)

Will you work overtime whenever scheduled or requested? *

Yes
No

Have you ever been employed by THIS NURSING FACILITY? *

Yes
No

If yes, give position(s) and date(s) of employment?

Would you accept part-time work? *

Yes
No

Would you accept temporary work? *

Yes
No

Special skills you possess:

Business machines and/or medical equipment you can operate (key-punch machine, tabulating machine, billing machine, etc.):

Long-range occupational goals: *

Education *

Include name & location, major studies, graduated/grade completed for 1) High School, 2) College, 3) Nursing School, 4) Special Schooling or training.

Professional License and Certification

Include type, state, date issued, and number.

Employment History *

List all previous employers for whom you have worked for during the last six years with salary of each employer (start with most recent). Explain any lapses between times when employed. Include: 1) Name & Address of Employer, 2) Month/Year Started, 3) Month/Year Ended, 4) Salary, 5) Position, 6) Supervisor, 7) Reason for Leaving

Comments regarding any lapses, if applicable:

Have you ever been discharged from a job or forced/asked to resign? *

Yes
No

If yes, explain:

Have you ever been counseled, verbally or in writing, for a violation of prior employers SAFETY RULES? *

Yes
No

If yes, explain:

Have you ever been counseled, verbally or in writing, for violations of any company policy of a prior employer? *

Yes
No

If yes, explain:

Are you now a member of the Reserve or National Guard? *

Yes
No

Have you ever served in the U.S. Armed Forces? *

Yes
No

If yes, 1) what branch, 2) type of discharge, 3) dates of duty?

List duties in the military or special training that has prepared you for the position you are applying for.