Online Employment Application - Lisner-Louise-Dickson-Hurt Home

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(IF YOU ARE NOT A UNITED STATES CITIZEN AND YOU ARE NOT LEGALLY ELIGIBLE TO WORK IN THE UNITED STATES, YOU CANNOT BE EMPLOYED AT THE LISNER-LOUISE-DICKSON-HURT HOME.)

Please provide any professional license or certification numbers if applicable to the position for which you are applying

License or Certification Number

Issued By Whom?

First Name

Last Name

Date of Last Renewal

Has your license or certification ever been suspended or revoked by any state?

Yes

The Home operates on a 7 days-a-week, 24 hours-a-day schedule. It may be necessary for you to work any shift as well as weekends and holidays. Are you available to meet these requirements, as needed?

Yes

If no, please explain

Please indicate below in your order of preference, with “1” being your first choice and “3” being your last choice, which shift(s) you prefer to work:

Day Shift (7:00 a.m. – 3:30 p.m.)

Evening Shift (3:00 p.m. – 11:30 p.m.)

Night Shift (11:00 p.m. – 7:30 a.m.)

Are you available for full-time employment?

Yes

Are you available for part-time employment?

Yes

Are you available for temporary or seasonal (summer only) employment?

Yes

Are you available for on-call employment?

Yes

EDUCATION

EMPLOYMENT HISTORY

Please give an accurate and complete employment history. Be sure to include any relevant volunteer experience you may have had. Start with your current or most recent employer.

Employed (State month and year)

Name of Immediate Supervisor

Salary or Wages Paid

Job Title/Description of Duties

Telephone

Area Code

Phone First 3

Phone Last 4

Name of Immediate Supervisor

Salary or Wages Paid

Beginning

Job Title/Description of Duties

Employed (State month and year)

From

Name of Immediate Supervisor

Salary or Wages Paid

Beginning

Job Title /Description of Duties

Employed (State month and year)

From

Name of Immediate Supervisor

Salary or Wages Paid

Beginning

Job Title /Description of Duties

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We may contact any or all of the employers listed above unless you indicate those you DO NOT want us to contact:

Employer/Company Number(s)

Please account for any periods of time during your work history when you were unemployed:

Are any of your relatives currently working for us?

Yes

If yes, please list their names :

Are you over 18 years of age?

Yes

If no, can you submit a work permit?

Yes

IF YOU CANNOT PRODUCE A VALID WORK PERMIT AND YOU ARE UNDER 18 YEARS OF AGE, YOU CANNOT WORK AT THE LISNER-LOUISE-DICKSON-HURT HOME.

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The information provided in this application for employment is true, correct, and completes to the best of my knowledge. If you employ me, I understand that false or misleading information given in my application or interview(s) may result in discharge and that my first 90 days of employment will be probationary, with the possibility of extension at the Home’s discretion. In consideration of my employment, I agree to conform to the rules and regulations of the Lisner-Louise-Dickson-Hurt Home and understand that my employment and compensation can be terminated, with or without cause, and with or without notice at any time, at the option of the Home or myself. I also understand that nothing appearing in the Home’s employee handbook or any other publication changes this “at-will” relationship.

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I authorize you to make such investigations and inquires of my personal employment history from my past employers as may be necessary in arriving at an employment decision. I hereby release employers, schools, or other individuals from all liability in responding to inquiries in correction with my application for employment.

Signature of Applicant

NOTE

Your application will be considered active for 30 calendar days. After that time, if you continue to have interest in employment with the Lisner-Louise-Dickson-Hurt Home, you may be required to submit another application.