Applicant Information
     
Full Name:
Last, First, M.I.		      Date:
 
 Address:  
 
  Street Address Apartment/Unit #
City:

  		State
  		Zip Code:
 
Phone:
Email Address:
 
Date Available:
Social Security No:
  		Date of Birth
Position Applied For:

  		Desired Salary: $
Are you a Citizen of the United States?:
If no, are your authorized to work in the U.S.?
Have you ever worked for this company?
       If so, when?    
Have you ever been convicted of a felony?
   
If yes, explain:
Have you ever been debarred or excluded from, or worked for someone who has been debarred or excluded from, Medicare, Medicaid or any other federal healthcare program?
If yes, explain:
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?
Have you been convicted of a crime (excluding misdemeanors and traffic offenses) and/or released from confinement following a conviction of any criminal offense within the past 7 years?
If yes, explain:
Are you presently charges with any violation of the law other than traffic violation?
If yes, explain:
Did a Guardian employee refer you for this position?
If yes, please give us the employee's name:
Other Referral Source:
   
EDUCATION
   
High School:
  		Address:
From:

  		To:
  		Did You Graduate?
Degree:
College: Address:
From:
To: Did You Graduate?
Degree:
Other: Address:
From:
To: Did You Graduate?
Degree:
List other skills applicable to the position for which you are applying, including computer experience, typing speed, etc:
List languages spoken other than English:
   
REFERENCES- Please list three professional references
   
Full Name: Relationship:
Company: Phone:
Address:
   
Full Name: Relationship:
Company: Phone:
Address:
   
Full Name: Relationship:
Company: Phone:
Address:
   
EMPLOYMENT HISTORY - Please list your most recent employer first. (DO NOT LIST -"SEE RESUME")
   
Company:
  		Phone:
 
Address:
  		Supervisor:
 
Job Title:  
Responsibilities:
From:
To: Reason for Leaving:
May we contact your previous supervisor for a reference?
   
Company: Phone:
Address: Supervisor:
Job Title:  
Responsibilities:
From:
To: Reason for Leaving:
May we contact your previous supervisor for a reference?
   
Company: Phone:
Address: Supervisor:
Job Title:  
Responsibilities:
From:
To: Reason for Leaving:
May we contact your previous supervisor for a reference?
   
MILITARY SERVICE
   
Branch:
From: To:
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
   
DISCLAIMER AND SIGNATURE
   
I understand and agree that I am offered employment by the facility, my employment will be for no definite term and that either I or the facility will have the right to terminate the employment relationship at any time, with or without cause and with or without notice. I also understand that this status can only be altered by a written contact of employment which is specific to all material terms and is signed by me and the Administrator of the facility

I understand, if I am an unlicensed person who has face-to-face patient/client contact, that the agency will perform a criminal history check per State Regulations as well as a check of the Nurse Aide Registry and Employee Misconduct Registry. I understand that: 1) the purpose of the Employee Misconduct Registry is to ensure that unlicensed personnel who commit acts of abuse, neglect, exploitation, misappropriation, or misconduct against residents and consumers are denied employment in DADS-regulated facilities and agencies; 2) the State maintains a registry of all nurse aides who are certified to provide services in nursing facilities and skilled nursing facilities licensed by the Department of Aging and Disability Services (DADS) and they review and investigate allegations of abuse, neglect, or misappropriation of resident property by informal reconsideration and a formal hearing before the finding is placed on the registry; 3) All DADS-regulated facilities and agencies are required to check the Employee Misconduct Registry and Nurse Aide Registry before hire to determine if I am listed in either registry as having committed an act of abuse, neglect, exploitation, misappropriation, or misconduct against a resident or consumer and am, therefore, unemployable.

I certify that my information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

Release: I hereby authorize any prior employer to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license history.