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Daniels House Nursing Home Application Form

Date Available
Position
Shift	Full Time Part Time Temporary
	Days Evenings Nights
Have you ever worked for any Whittier Health Network facility before?	Yes No
	If yes:
Facility
Position
Date

	Personal Information
First Name
Middle Name
Last Name
	Your Address
Address
City
State
Zip Code
Phone #
Other Phone #
May we contact you by e-mail?	Yes No
	If yes:
E-mail Address
Are you 18 years of age or older?	Yes No
	If No, please provide appropriate working permit.
Are you legally authorized to work in the United States?	Yes No
	If yes, you will be required to submit proof if hired.
Will you now or in the future require sponsorship for employment visa status? (e.g., H-1B visa status)	Yes No
How did you become aware of the position for which you are applying? (Please give individual or source)
Please list any relatives employed by the Company
	Education and Training
	Grammar or Grade School
Name of School
Location(City, State)
Courses Taken
Completed	Yes No
Type of Degree or Certificate Received
	High School
Name of School
Location(City, State)
Courses Taken
Completed	Yes No
Type of Degree or Certificate Received
	College
Name of School
Location(City, State)
Courses Taken
Completed	Yes No
Type of Degree or Certificate Received
	Vocational or Business
Name of School
Location(City, State)
Courses Taken
Completed	Yes No
Type of Degree or Certificate Received
	Other
Name of School
Location(City, State)
Courses Taken
Completed	Yes No
Type of Degree or Certificate Received
	Professional Licenses or Certificates
Type
Organization or State Issued
Date Issued
Number
If not received, have you applied for endorsement or registered to take the State Board Exam?	Yes No
	If yes, when:

Has your license, certification or registration ever been revoked, suspended or restricted in any way?	Yes No
If yes, please explain
	Work Experience
List all of your places of employment beginning with the most recent.You may include work performed on a volunteer basis. Please account for any time period between positions when you were not working. Whittier may contact any of these persons or entities to obtain an employment reference.
Employer
Address
Phone #
Supervisor
Position
Wage
Employed From Date
Employed To Date
Reason for leaving
May we contact this reference?	Yes No After Offer
	---------------------------------------------
Employer
Address
Phone #
Supervisor
Position
Wage
Employed From Date
Employed To Date
Reason for leaving
May we contact this reference?	Yes No After Offer
	---------------------------------------------
Employer
Address
Phone #
Supervisor
Position
Wage
Employed From Date
Employed To Date
Reason for leaving
May we contact this reference?	Yes No After Offer
	---------------------------------------------
Have you ever been discharged from a position?	Yes No
If yes, please provide details, including when and reason for discharge.
If your former employment, references, or education are under a name other than indicated on front of application, please indicate.
Are you on the Office of Inspector General List of Excluded Individuals / Entities?	Yes No
Conviction of a criminal offense will not necessarily preclude your employment.
Have you ever been convicted of a felony?	Yes No
If Yes, please explain.
An applicant for employment with a sealed record on file with the commissioner of probation may answer "no record" with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, any applicant for employment may answer "no record" with respect to any inquiry relative to prior arrests, court appearances and adjudication in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution.
	Application Statement
I affirm that the information provided in conjunction with the application process, including the information provided on this Application for Employment and any resume submitted is true, accurate and complete to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I authorize the Company to investigate all information pertinent to my application for employment in order to determine my qualifications for employment, which may include contacting former and current employers or any other person or entity listed on this application. I authorize all persons and entities having information relevant to my application to provide that information to the Company and I agree to hold harmless the Company and all those providing information to the Company from any liability arising out of or as the result of the request for, provision of, or use of such information. I also understand that as a condition of employment I will be required to, and hereby consent to, an Office of Inspector General check, a criminal record background check, substance abuse test, and a pre-employment medical examination. I understand that any offer of employment may be rescinded or my employment terminated if my references are inadequate or unacceptable to the Company, or if the results of my Office of Inspector General check, criminal record background check, substance abuse test or pre-employment medical examination are unsatisfactory. I further understand that if I am hired by the Company, I must abide by all the rules and policies of the Company which, other than the at-will employment policy, may be changed without notice at the discretion of the Company. I understand that completion of this Application for Employment does not assure me of a position with the Company. I also under- stand that neither this application nor any other document constitutes a contract of employment for a specific term and that any employment relationship that may be established will be at-will, and may be terminated at any time for any reason or no reason by me or the Company. I understand that any omission, misrepresentation, or falsification in conjunction with this application process may be grounds for denial of employment, or, if hired, immediate termination of employment. While the Company does not require or request applicants or employees to take a lie detector test, Massachusetts law requires the following notice: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.
I ACKNOWLEDGE THAT I HAVE READ OR HAVE HAD READ TO ME AND UNDERSTAND THE FOREGOING AND SO AUTHORIZE AND RELEASE THE COMPANY.