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Application for Employment
Name:
*
Date:
Upload Resume:
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Email:
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Phone:
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Mailing Address:
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City:
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State:
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Zip Code:
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Are you legally eligible for employment in the United States?:
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Yes
No
Are you at least 18 years of age?:
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Yes
No
If you are under 18 years of age, can you provide required proof of eligibility to work?
Yes
No
A criminal background check will be required from each applicant prior to an offer of employment. A willful false answer to the question below will result in termination of employment. A conviction is defined as any crime which you have plead guilty to, have been found guilty in a court of law, plea bargained with an attorney, paid a fine, been incarcerated, done community service, etc. Felonies, misdemeanors, summary offenses, and local ordinance violations apply. Evidence of a criminal record does not necessarily disqualify you from employment at Menorah Park.
Have you ever been convicted of a crime?:
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Yes
No
If so, describe:
Position(s) Applied for:
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Please mark your availablity:
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How did you learn of the position you are applying for?:
Shift(s)
7AM - 3PM
3PM - 11PM
11PM - 7AM
Week Days:
Status:
Per-Diem
Part-Time
Full-Time
Date available to start:
Employment History:
List your last THREE employers starting with your most recent - reference to your resume is unacceptable.
Employer:
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Address:
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Position:
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Employed from:
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Starting salary:
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Ending salary:
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Briefly describe your duties:
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Reason for leaving:
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Supervisor:
*
Supervisor Phone #:
*
Employer:
Address:
Position:
Employed from:
Starting salary:
Ending salary:
Briefly describe your duties:
Reason for leaving:
Supervisor:
Supervisor Phone #:
Employer:
Address:
Position:
Employed from:
Starting salary:
Ending salary:
Briefly desicribe your duties:
Reason for leaving:
Supervisor:
Supervisor Phone #:
Have you ever been previously employed by Menorah Park?
*
Yes
No
If yes, please provide dates:
May we contact your current employer for a reference?
Yes
No
Edutation:
High School:
College:
Nursing School:
Graduate School:
Other:
Licensing / Certification Information:
This section to be completed by licensed or certified candidates only
Are you presently licensed/certified to practice in New York State?
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Yes
No
Is your license/certification in good standing without prior actions against?
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Yes
No
If no, explain details:
License or Certificate #:
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Expiration:
*
Check areas of experience:
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Acute Care
Med / Surg
ICU
Long-Term Care
Home Health Care
Psychiatric
Doctor Office
Other
Agreement:
As part of the hiring process, you should be aware that we will be checking your references. We may contact those persons whom you have identified to us as potential references. In addition, we may also contact other friends, acquaintances, business associates, local, state or federal law enforcement agencies, state licensing agencies or anyone who knows you. When we contact a reference, we may ask a series of questions relating to your personal background, education, work experience, character, criminal conviction records and/or personality. I have read and fully understand the foregoing. I hereby voluntarily consent to allow the Jewish Health & Rehabilitation Center or any of its employees or designees, to check my references by contacting any person whom they deem to be an appropriate reference. The Jewish Health & Rehabilitation Center representatives may ask questions about my personal background, education, work experience, character, criminal conviction records and/or personality.
I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I agree that the Menorah Park shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in this application for employment with the Jewish Health & Rehabilitation Center. I also authorize the companies, schools, law enforcement agencies, state licensing agencies and persons named in this application to give any information regarding my employment, character, and qualifications. I hereby release said companies, schools, law enforcement agencies or persons from liability for any damage for issuing this information. I understand that any misleading or incorrect statements may render this application void, and if employed, would be cause for termination. I understand that, if employed, I have been hired at the will of the employer and that my employment may be terminated at will, at any time, and with or without cause, the employer’s only obligation being to pay wages due and owing at the time of the termination unless otherwise provided in the collective bargaining agreement with SEIU 1199 Upstate. Upon my termination, I authorize the release of reference information regarding my employment with the Jewish Health & Rehabilitation Center and release the same from any liability for any damage for issuing this information.
Agree
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