Personal Information

Last Name:

First Name:

MI:

SSN# (Last 4):

Cell Phone:

Best Time to Call:

Home Phone:

Best Time to Call:

Are You Entitled to work in the United States?

Yes

No

Position Applying For:

If you served in the United States Military, please state if you received any training or experience that would assist you in performing the job for which you applied:

Have you been convicted of a crime?

Yes

No

If yes, please explain:

Referred by:

Applying for:

Full Time

Part Time

Are you at least 18 years of age?

Yes

No

Under age 18, do you have a work permit?

Yes

No

What other name have you been known by?

How did you hear of the position?

Shift Preference?

7am - 3pm

3pm - 11pm

11pm - 7am

Date Available:

Provide name(s) of family or friend(s) currently employed at LeRoy Village Green RHCF:

Have you submitted an application with our company before?

Yes

No

If yes, provide the application date:

Have you ever been employed by our company?

Yes

No

If yes, provide employment dates:

From:

To:

Prior Work Experience

Current or Most Recent

Employer:

Phone:

Name of Immediate Supervisor:

Position/Job Title:

Dates of Employment

From:

To:

Pay:

Reason for Leaving:

May We Contact?

Yes

No

Prior

Employer:

Phone:

Name of Immediate Supervisor:

Position/Job Title:

Dates of Employment

From:

To:

Pay:

Reason for Leaving:

May We Contact?

Yes

No

Prior

Employer:

Phone:

Name of Immediate Supervisor:

Position/Job Title:

Dates of Employment

From:

To:

Pay:

Reason for Leaving:

May We Contact?

Yes

No

Education

High School

Name/Location:

Last Year Complete:

9

10

11

12

Degree:

Major or Emphasis:

College/University

Name/Location:

Last Year Complete:

1

2

3

4

Degree:

Major or Emphasis:

Trade School

Name/Location:

Last Year Complete:

Degree:

Major or Emphasis:

Other

Name/Location:

Last Year Complete:

Degree:

Major or Emphasis:

List any applicable special skills, training or proficiencies.

RN License #:

LPN License #:

CNA Registry:

Expiration Date:

Personal References

Reference 1

Name:

Telephone:

Reference 2

Name:

Telephone:

Reference 3

Name:

Telephone:

Have you ever had a non-criminal finding of abuse, neglect or misappropriation of resident funds sustained against you?

Yes

No

Is there currently a non-criminal on going investigation of abuse, neglect or misappropriation of resident property that involves you?

Yes

No

If so, please describe fully the facts of the investigation:

APPLICANT'S STATEMENT:

The above information is complete and true to the best of knowledge.
If employed by LeRoy Village Green RHCF, I agree to abide by its rules and regulations.
Any misrepresentation or omission will also be cause for CLeRoy Village Green RHCF refusing to hire me.
I hereby authorize all persons, companies and corporations to release and provide any and all information regarding my employment to LeRoy Village Green and release LeRoy Village Green from all liabilities for issuing this information.
I agree as a condition of my employment that I must take and pass a physical examination and drug test at no personal expense to me. I also agree that the examining physician may disclose findings of that examination to LeRoy Village Green or an authorized agent thereof.

Signature

Reset

LeRoy Village Green RHCF, Inc. is an Equal Opportunity Employer and complies fully with Federal and New York State laws prohibiting discrimination in employment because of sex, age, race, color, creed, national origin, religion, marital status, availability for military services, disability, sexual orientation or arrest/conviction record.

LeRoy Village Green RHCF, Inc. will make reasonable accommodations to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodations would impose an undue hardship or a significant risk of substantial harm.

Employment Form

Personal Information

Prior Work Experience

Education

Personal References

APPLICANT'S STATEMENT:

We are fully accredited by the State of New York, and we maintain a reputation as one of the finest long-term care facilities in Western NY.