Application For Employment - CNA/PCA
Date
Position(s) Applied For
Social Security Number
First Name
Last Name
Marital Status
Date of Birth
Home Phone
Cell Phone
Email
Address
City
State/Province/Region
Name of employer
Current Employer Phone
Are you licensed/certified for the job applied for?
Name of license/certification
Issuing State
Expiration
Explain
Emergency Contact Information
Contact #1 Name
Contact #1 Phone
Contact #1 Relationship
Contact #2 Name
Contact #2 Phone
Contact #2 Relationship
Availability
Date you are availabile to work
Desired Wage/Salary
Below, please list all days and times you are available for work. *Please note that some weekends are mandatory for employment with GHS.
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Please list ALL counties/areas that you are willing to travel for work
Who?
If yes, state nature of the crime(s), when and where convicted and disposition of case(s).
*(Note: No applicant will be denied employment based solely on the grounds of conviction of a criminal offense. The nature of the offense, date of the offense, surrounding circumstances, and relevance of the offense to the position(s) applied for might and can be the primary reason for a “no” hire.
What languages?
Do you understand sign language and/or can hand sign
Education Background, Training & Military Experience
All positions at GHS requires a minimum educational level of a High School Diploma or equivalent.
High School
City
State
College Name
City
State
Other Institutes
What machines or equipment have you operated that relates to the position you have applied for?
Are there any skills, experience or other qualifications that you feel would assist you in performing the duties of the position you have applied for?
Employment History
List your last three (3) employers stating with the most recent.
Employer #1
Employer #1 Phone
Employer #1 Commencement Date
Employer #1 Departure Date
Employer #1 Reason for Departure
Employer #1 Supervisor's Name
Employer #1 Supervisor's Phone
Employer #1 Duties
Employer #1: May we contact this employer, If no explain.
Employer #2
Employer #2 Phone
Employer #2 Commencement Date
Employer #2 Departure Date
Employer #2 Reason for Departure
Employer #2 Supervisor's Name
Employer #2 Supervisor's Phone
Employer #2 Duties
Employer #2: May we contact this employer, If no explain
Employer #3
Employer #3 Phone
Employer #3 Commencement Date
Employer #3 Departure Date
Employer #3 Reason for Departure
Employer #3 Supervisor's Name
EmployEmployer #3 Supervisor's Phoneer #3 Supervisor's Name
Employer #3 Duties
Employer #3: May we contact this employer, If no explain.
Military Experience
If yes, please include branch and highest rank
If dishonorably discharged, please explain why.
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Reference #1 Name
Reference #1 Phone
Reference #1 Number of Years Aquainted?
Reference #2 Name
Reference #2 Phone
Reference #2 Number of Years Aquainted?
Reference #3 Name
Reference #3 Phone
Reference #3 Number of Years Aquainted?
If you are applying for a position that requires driving, please complete this section:
License Number
State
If so, state when and why.
If you are selected for an interview, you are required to present a copy of your driving record that is not more than four (4) weeks old. After being hired, a copy of this driving record will be placed into your personnel file. An annual update record is required.
FALSE INFORMATION GIVEN OR IMPLIED ON AN APPLICATION IS GROUNDS FOR IMMEDIATE DISMISSAL WITHOUT FUTHER NOTICE.
In exchange for the consideration of my job application by GHS, Inc., I agree that neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of GHS, Inc. or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Director or the company. Both the undersigned and the Director may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits. I hereby state that all information provided is accurate and may be verified by you. I agree that I may be discharged if GHS at any time learns of falsification or material omission in the information provided on this application form and related documents. GHS may contact my former employer in connection with the consideration of my employment with them. I hereby release GHS, its affiliates, successors and assign, and all references from any liability that might be claimed because of information provided by such references. I agree that I will follow all company policies, rules, procedures, and other directions pertaining to my employment. I understand that GHS reserves the right to add, change, and/or delete any policies, procedures, work rules, and/or benefits at any time. NO CONSIDERATION WILL BE GIVEN TO ANYONE WHO DOES NOT SIGN THE ABOVE STATEMENT.
Applicant Name
Date
Geenline Health Services, Inc. is committed to the principle of equal employment opportunity for all applicants, and to providing them with a work environment free of harassment and/or discrimination. All employment decisions are based on each applicant’s qualifications, training, experience, and the company’s need without regard to race, religion, sex (including pregnancy), origin, age, disability, sexual orientation, gender, marital status, or any other status protected by all applicable laws.
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