berrienemploymentapp

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Berrien Nursing & Rehabilitation Center Employment Application

An Equal Employment Opportunity Employer • Drug Free Workplace • Tobacco Free Workplace
We comply with all applicable state and federal civil rights and equal employment laws and regulations

Your Contact Information

First Name

Middle Name

Last Name

Today’s Date

Phone

Cell

Street Address

City

State

Zip

Which position are you applying for?

CNA Other

If “Other” please specify:

Date available for work:

Referred by:

Social Security Number:

Type of Employment Desired:

Full Time Part Time PRN

Would you consider working weekends?

yes no

Would you consider working holidays?

yes no

Have you ever been convicted of a felony?

yes no

If yes, please explain:

Have you ever been employed here before?

yes no

Are you legally eligible for employment in this country?

yes no

Licenses and Professional Data

Type:

Expiration Date:

License Status:

Eligible for License Currently Licensed

License Number:

Registration Status:

Eligible for License Currently Licensed Eligible for Registration

Professional Certifications Status:

In Good Standing On Probation Suspended Revoked

If other than “In Good Standing", please explain:

Have any disciplinary actions ever been initiated and/or are any now pending against you by any state licensure board?

yes no

If yes, please explain:

Have you ever been suspended, sanctioned, or otherwise restricted from participation in any private, federal, or state health insurance program (such as Medicare or Medicaid)?

yes no

If yes, please explain:

If your answer is “yes” to any of the aboive, you will not automatically be disqualified from employment consideration, except as required by state or federal law.

Employment History

(1) Employer Information

Name of Company:

Phone

Prior to acceptance of this position, may we contact your previous employer?

yes no

Address

Dates Employed

From:

To:

Name of Supervisor:

Job Title:

Salary:

hourly monthly yearly

Amount paid according to your selection above:

Duties:

Reason for Leaving:

(2) Employer Information

Name of Company:

Phone

Prior to acceptance of this position, may we contact your previous employer?

yes no

Address

Dates Employed

From:

To:

Name of Supervisor:

Label

Salary:

hourly monthly yearly

Amount paid according to your selection above:

Duties:

Reason for Leaving:

(3) Employer Information

Name of Company:

Phone

Prior to acceptance of this position, may we contact your previous employer?

yes no

Address

Dates Employed

From:

To:

Name of Supervisor:

Job Title:

Salary:

hourly monthly yearly

Amount paid according to your selection above:

Duties:

Reason for Leaving: