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Jasper Memorial Hospital
Retreat Nursing Home
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Job Application
Name
First
Middle
Last
Present Address
*
City
*
Zip Code
*
State
*
Telephone No.
Is this a Home or Cell Number?
Home
Cell
Previous Address (If within the last 6 years)
Email
Email
Confirm Email
Position(s) applied for
Rate of pay expected $
Would you prefer to work full or part time?
Full Time
Part Time
Specific days and hours if part time:
List Volunteer or Community Service Positions (work) which you feel are related to the position for which you are applying:
Briefly state any special skills or qualifications you have which you feel are related to the position for which you are applying:
Were you previously employed by us?
No
Yes
If yes, when:
Were you referred by a current employee?
First
Last
If your application is considered favorably, on what date will you be available for work?
Person to be notified in case of accident or emergency:
First
Last
Relationship
Phone Number
Address
Highest Level of Education
High School
College
Other (Specify Below)
Name and Address of School
Did you Graduate?
Yes
No
List Diploma or Degree
Most Recent Employer
Phone Number
Address
City
State
Previous Employer
Phone Number
Address
City
State
Were you in U.S. Armed Forces?
No
Yes
If yes, what branch?
Date of Duty Start:
Date of Duty End:
List duties in the military including special training:
Personal Reference (1)
First
Last
Occupation
Address
Phone Number
Personal Reference (2)
First
Last
Occupation
Address
Phone Number
Do you agree to the terms set forth in this application?
*
Yes
No
This institution does not discriminate in hiring or in any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No Question on this application is intended to secure information to be used for such discrimination. I voluntarily give the institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physician examination which relates to the essential duties would be required to perform. I understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. If employed, I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory evidence of identity and eligibility of employment.
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