Please fill out our employment application below. To be sure your application is properly evaluated all questions should be answered as carefully and completely as possible. Feel free to add any information which will help us evaluate your qualifications for employment.

Employment Desired

Position:

Date you can start:

Full timePart timeTemporary

Hours available:

Have you ever been employed by Heritage of Foley
YesNo

If yes, please complete the following:

Date of employment:

Position held:

Immediate Supervisor:

Reason for Leaving:

Do you currently have any relatives employed at Heritage of Foley? YesNo

If so, who?

REFERRED BY
Current Staff Member (Employee's name)
Ad (Name of Publication)
Other

Heritage of Foley does not illegally discriminate on account of an applicant's age. If you are under 18, you may be required to prove your age for some jobs where state laws or regulations impose restrictions.

Are you 18 years of age or older? YesNo

Scheduling

Every nursing facility must be staffed 7 days a week, 24 hours a day. Work schedules are varied and require flexibility. Based on our staffing needs, we may not always be able to accommodate your scheduling preferences. Therefore, please consider carefully all of your personal time commitments before responding to the following questions.

Check shift preference: DayEveningNightNo preference, I can work any shift

Education

High School

Name and Location

Did you Graduate?

YesNo

Degree Received

Subject studied

College

Name and Location

Did you Graduate?

YesNo

Degree Received

Subject studied

Trade School

Name and Location

Did you Graduate?

YesNo

Degree Received

Subject studied

Other (military, seminars, schools, etc.)

Name and Location

Did you Graduate?

YesNo

Degree Received

Subject studied

License/Certification Complete this section if a license/certification is required to perform the duties of the job for which you are applying.

License/Certification

State

Number

Expiration Date

If you don't have the required license for this job, have you applied? YesNo

If an exam is required to obtain the required license, give scheduled date

If not licensed in this state, have you applied for reciprocity? YesNo

Skills List any additional skills you have that add to your qualification for this position (for example, EMT or CPR training).

Work Experience

Indicate all work experience beginning with your current or most recent position. Complete all sections.








References

List any other references other than relatives or former employers that we may contact.

Name and Phone

Occupation

Address

Years Acquainted


Name and Phone

Occupation

Address

Years Acquainted


Name and Phone

Occupation

Address

Years Acquainted

This statement is to affirm Heritage of Foley’s policy for providing equal opportunities to all employees and applicants for employment in accordance with all applicable equal employment opportunity laws, directives and regulations of federal, state and local governing bodies or agencies thereof.

Heritage of Foley will not discriminate against any employee or applicant for employment because of race, religion, national origin, sex, disability, age or membership in any other protected class.

Heritage of Foley will work to ensure that all employment practices are free of discrimination.

By signing below, I am certifying that all information provided by me in this application is true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be grounds for dismissal, whenever discovered.

I authorize investigation of the truth and completeness of all information provided by me in this application. In consideration of providing information to assist me in my employment search, I hereby release any and all sources of such information, along with their agents and employees, from claims I may have arising out of the disclosure of information about me.

In consideration of the Employer considering me for employment, I hereby release the Employer, along with its agents and employees from any and all claims I may have arising from the Employer seeking information about me in connection with my application for employment with the Employer.

By signing below, I am agreeing that if I am hired, unless otherwise provided in a signed written agreement, my employment may be terminated by me or by the Employer at any time, for any reason, and with or without cause. I agree that neither this application nor any personnel manual which I may receive upon employment is intended to be a contract of employment.

I agree that any offer of employment is conditioned on (i) verification of my right to work in the United States; (ii) passing a Tuberculosis test (if applicable to the position); (iii) satisfactory completion of a criminal background investigation, and if applicable, a driving record investigation; and (iv) receipt of favorable references (as determined in the sole discretion of the Employer). I agree that any offer of employment may also be conditioned on (i) demonstration of physical and mental ability to perform essential job functions (when a physical exam or testing is required for the job position, all applicants will be given the same testing); (ii) passing a literacy examination; and (iii) verification of any required license or registration and confirmation that no discipline, investigation, or condition will affect my ability to work under that license or the license of another, as determined in the Employer’s sole discretion.

Electronic Signature

Date