Employment Application

Application for Employment
Please provide all information necessary for employment consideration. Incomplete or incorrect information may disqualify you for employment. Fields marked with a red border are required to submit the application.
Positions Applying for:
Shift Preferred:
1st2nd3rdAnyOn Call
FT/PT
Full-TimePart-TimeAny
Hours Available for Work:
Date Available for Work:
Month - Day - Year
Salary Expected:
Personal
Your Name:

First Name
Middle Name
Last Name

Address

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Date of Application:
Month - Day - Year
Home Telephone:
Area Code - Phone Number
Other Telephone:
Area Code - Phone Number
Email Address:
May we use your email address to contact you?
Yes
No
Are you legally eligible for employment in the United States?
Yes
No
Last four (4) digits of Social Security #:
Are you at least 18 years of age?
Yes
No
How did you hear about us? If referred, please indicate by whom?
List all other names you have had (aliases, maiden, other, married, etc.)
Were you previously employed by Sisters of Charity Motherhouse, Mother Margaret Hall, or Bayley?
Yes
No
If Yes, list positions and dates of employment:
Do any of your relatives currently work for Sisters of Charity Motherhouse, Mother Margaret Hall or Bayley?
Yes
No
If Yes, list name and relationship:
Please list all appropriate licenses or certifications which would qualify you to work at Sisters of Charity Senior Care Corporation, i.e. nursing license.
Licenses and Certifications

TYPE NUMBER EXPIRATION DATE

1.

2.

3.
Have you filed any fraudulent claim(s) against any of your present or past employers?
Yes
No
If Yes, please explain:
Were you ever convicted of a crime, including DUI/DWI? (Include minor traffic violations)
Yes
No
If YES, give date, location, and offense.

(A conviction will not necessarily disqualify you from employment.)
Date, Location, Nature of Offense:
NOTE: Organization policy requires ALL convictions to be listed, including misdemeanors, felonies, and convictions satisfied with a ticket and payment. Please make sure EVERY conviction is listed to avoid being disqualified from consideration for employment.
Are you currently obliged by any employment contract or agreement which would prohibit your employment with Sisters of Charity Senior Care Corporation?
Yes
No
If Yes, please explain:
Education

Education History:

	Name and Location of School	Course of Study	Number of Years Completed	Did you Graduate?	Degree or Diploma
Elementary
Junior High / Middle
High School
Business / Trade / Technical
College
Graduate

List other experiences, skills, qualifications, scholastic honors or licenses which you feel would qualify you for work with the Sisters of Charity Senior Care Corporation:
Military Service Record
Did you serve in the U.S. Armed Forces?
Yes
No
If Yes, what branch?
Dates of Duty:
From:
Month - Day - Year
To:
Month - Day - Year
Rank at Discharge:
Employment History
List below, beginning with most recent, all present and past employment.

Please fill out this section even if you submitted a resume. Add employers not listed on your resume. Failure to complete all requested information, including wages and dates of employment may delay or disqualify you from consideration. Add additional information in the space provided if necessary.
Company 1
Company 1 Name:

Company 1 Address:

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Company 1 Telephone:
Area Code - Phone Number
Company 1 Employment Dates (month and year, include start and end dates)
Company 1 Job Title:
Company 1 Supervisor and Title:
Company 1 Starting Salary:
Company 1 Ending Salary:
Company 1 Job Responsibilities:
Reason for Leaving Company 1:
May we contact Company 1?
Yes
No
Company 2
Company 2 Name:

Company 2 Address:

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Company 2 Telephone:
Area Code - Phone Number
Company 2 Employment Dates (month and year, include start and end dates)
Company 2 Job Title:
Company 2 Supervisor and Title:
Company 2 Starting Salary:
Company 2 Ending Salary:
Company 2 Job Responsibilities:
Reason for Leaving Company 2:
May we contact Company 2?
Yes
No
Company 3
Company 3 Name:

Company 3 Address:

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Company 3 Telephone:
Area Code - Phone Number
Company 3 Employment Dates (month and year, include start and end dates)
Company 3 Job Title:
Company 3 Supervisor and Title:
Company 3 Starting Salary:
Company 3 Ending Salary:
Company 3 Job Responsibilities:
Reason for Leaving Company 3:
May we contact Company 3?
Yes
No
Company 4
Company 4 Name:

Company 4 Address:

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Company 4 Telephone:
Area Code - Phone Number
Company 4 Employment Dates (month and year, include start and end dates)
Company 4 Job Title:
Company 4 Supervisor and Title:
Company 4 Starting Salary:
Company 4 Ending Salary:
Company 4 Job Responsibilities:
Reason for Leaving Company 4:
May we contact Company 4?
Yes
No
Company 5
Company 5 Name:

Company 5 Address:

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Company 5 Telephone:
Area Code - Phone Number
Company 5 Employment Dates (month and year, include start and end dates)
Company 5 Job Title:
Company 5 Supervisor and Title:
Company 5 Starting Salary:
Company 5 Ending Salary:
Company 5 Job Responsibilities:
Reason for Leaving Company 5:
May we contact Company 5?
Yes
No
REFERENCES
(Not former employers or relatives)
References

Name Occupation Day Phone Number

Reference 1

Reference 2

Reference 3
PLEASE READ CAREFULLY

Drug Free Workplace

Alcohol and Drug Screening Tests are administered as part of the post offer process and may occur during employment as specified by the Alcohol and Drug free Policy.

I declare the foregoing information to be a truthful and complete statement of facts which, if found false, will result in refusal of hire or termination of employment whenever such falsity is discovered.

I authorize my former employers, references indicated, any law enforcement agencies and all other sources deemed necessary to release to Sisters of Charity Senior Care Corporation any information necessary to make employment decisions. I release all parties concerned from any liability arising out of such investigation. I also understand that any offer of employment is contingent upon the successful completion of a post offer employment examination.

In consideration of my employment, I agree to comply with the rules and regulations of Sisters of Charity Senior Care Corporation. My employment is at will and such employment and compensation can be terminated with or without cause and with or without notice at any time at the option of either Sisters of Charity Senior Care Corporation or myself. I understand that no representative of Sisters of Charity Senior Care Corporation other than the president of Sisters of Charity Senior Care Corporation has any authority to enter any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, and any such agreement must be in writing, signed by the president.
Signature:
Signature Date:
Month - Day - Year
Applications are retained as required by law.

SISTERS OF CHARITY SENIOR CARE CORPORATION IS A SPONSORED MINISTRY OF THE SISTERS OF CHARITY OF CINCINNATI, MOUNT SAINT JOSEPH, OHIO.

TO THE APPLICANT: Please complete and place with your employment application
BACKGROUND CHECK INFORMATION
The information requested below is solely for the purpose of running a background check in connection with your application for employment.
Name

First Name
Middle Name
Last Name
Drivers License Number:
State Issuing License:
Enter any other names used (including maiden name):

First Name Middle Name Last Name

Name 1

Name 2
Addresses within the past seven years

Present Street Address:

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Prior Address #1:

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Prior Address #2:

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

List Additional Prior Addresses as Needed:

	TYPE	NUMBER	EXPIRATION DATE
1.
2.
3.

	Name	Occupation	Day Phone Number
Reference 1
Reference 2
Reference 3

Application for Employment

Personal

Education

Military Service Record

Employment History

Company 1

Company 2

Company 3

Company 4

Company 5

REFERENCES

PLEASE READ CAREFULLY

BACKGROUND CHECK INFORMATION