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APPLICATION FOR EMPLOYMENT
Applicants are considered for all the positions without regard to race, color, religion, gender, sexual orientation, age, citizenship or a non-job related disability or handicap:
Fields marked by * are required
Today's Date:
Date and time
Now
CNA
LPN
RN
Certification/License #:
State:
Year you first obtained certification/license:
Expiration Date:
Date and time
Now
Check all the jobs you are interested in:
Food Service Aide
Cook
Housekeeper
Maintenance
Clerical
Recreation
Supervisor
Dept. Head
Other
If other, Please explain:
Check Schedule you can work:
Full time
Part time
Doesn't matter
Weekends ok
Weekends NOT ok
Shift Preference:
7am-3pm
3pm-11pm
11pm-7am
Other
Doesn't matter
Prefer:
Nursing Homes
Assisted Living/Adult Day Health
Doesn't matter
Personal Information
*
First Name:
*
Last Name:
*
Address:
Address (Cont.):
*
City:
*
State:
*
Zip:
Cell Phone:
(
)
-
Second part
Third part
*
Telephone #:
(
)
-
Second part
Third part
*
E-mail Address:
Valid NJ driver's license:
Yes
No
Over 18 years old?:
Yes
No
Salary Expected:
Start date:
Date and time
Now
Legally authorized to work in U.S.:
Yes
No
Ever worked or attended school under another name:
Yes
No
If yes, please provide name:
Working for Parker
Have you ever worked for, or volunteered at, Parker Home:
Yes
No
If yes, please provide dates and job title or volunteer activity:
Have you filled out an application for Parker Home before:
Yes
No
Who Referred You To Parker Home?:
Are you related to anyone currently employed by Parker Home:
Yes
No
If yes, please provide name and relationship:
Emergency Notification:
Name:
Relationship:
Home Phone:
(
)
-
Second part
Third part
Cell Phone:
(
)
-
Second part
Third part
Work Phone:
(
)
-
Second part
Third part
To the best of your knowledge, are you physically and mentally able to perform the duties of the position for which you have applied:
Yes
No
If no, please explain:
Military Service
Military Service:
Yes
No
Branch:
Military Service Dates:
From:
Date and time
Now
To:
Date and time
Now
Honorable Discharge:
Yes
No
Please explain:
Ever been convicted of a crime:
Yes
No
If yes, please explain:
Name, Location of
HS, Technical School, College:
Major Subject:
Degree/Certificate:
Completed yes/No:
Your strengths:
Your weakness:
Long range goals:
Please provide the following information for the past 10 years.:
Current Employer:
Phone:
(
)
-
Second part
Third part
Your Salary $:
Address:
City:
State:
Zip:
Job Title & Responsibilities:
Supervisor's Name & Title:
Reason for Leaving:
Dates of Employment
From:
Date and time
Now
To:
Date and time
Now
May we contact your current employer for a reference?:
Yes
No
Past Employer 1:
Past Employer 2:
Phone:
(
)
-
Second part
Third part
Phone:
(
)
-
Second part
Third part
Your salary $:
Your Salary $:
Address:
Address:
City:
City:
State:
State:
Zip:
Zip:
Employment Dates:
Employment Dates:
From:
Date and time
Now
From:
Date and time
Now
To:
Date and time
Now
To:
Date and time
Now
Job Title & Responsibilities:
Job Title & Responsibilities:
Supervisor's Name & Title:
Supervisor's Name & Title:
Reason for Leaving:
Reason for Leaving:
Have you had more jobs than those listed above:
Yes
No
If yes, how many more years of work history?:
If any of them were in health care, please say how many years.:
Please print the name, telephone number and relationship of three other references.:
First Name:
First Name:
Last Name:
Last Name:
Phone:
(
)
-
Second part
Third part
Phone:
(
)
-
Second part
Third part
Relationship:
Relationship:
First Name:
Last Name:
Phone:
(
)
-
Second part
Third part
Relationship:
Voluntary Applicant Invitation to Self-Identify
This section of the employment application form will not be made available to interviewers or included in operating personnel records.
The following information is requested of all applicants in order to aid in complying with certain governmental recordkeeping and reporting requirements. In order to comply, we invite applicants to
voluntary
self-identify. The information obtained will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders and regulations. Submission of this information is
voluntary
and refusal to provide it will not subject you to any adverse treatment.
[Optional] Gender:
Male
Female
[Optional] Race/Ethnicity:
Hispanic/Latino
Asian
Amer.Ind./Alaskan
White
Native Hawaiian/Pacific Islander
Black/African American
Two or more Races
[Optional] If you are a Covered Veteran, please check the appropriate box. This information is
voluntary
; the information will not be used in our selection process.:
Vietnam Era Veteran
Disabled Veteran
Other Covered Veteran
Recently Separated Veteran
No Veteran Status
Definitions
(taken from Equal Opportunity Employment definitions):
White–
Person with origins in any of the original peoples of Europe, North Africa or the Middle East.
Black–
Persons having origins in any of the Black racial groups of Africa.
Hispanic–
Persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture, regardless of race.
Asian/Pacific Islander–
Persons having origins in any of the original peoples of the Far East, Southeast Asia, The Indian subcontinent, or the Pacific Islands. This area includes China, Japan, Korea, the Philippine Islands and Samoa.
American Indian/Alaska Native–
All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.
Definitions:
Veteran of the Vietnam Era–
Person who served on active duty for a period of more that 180 days, and was discharged or released there from with other than dishonorable discharge, if any part of such active duty occurred in the Republic of Vietnam between 2/28/61, and 5/7/75, or between 8/5/64 and 5/7/75 in all other cases.
Disabled Veteran–
Person entitled to disability compensation under laws administered by the Department of Veterans Affairs for a disability rated at 30% or discharged or released from duty due to a service connected disability.
Covered Veteran–
(i) Veterans who served on active duty in the Armed forces during war or in a campaign or expedition for which a campaign badge has been authorized. (ii) Veterans who, while serving on active duty in the Armed Forces, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985 (61Fed. Reg. 1209).
Recently Separated Veterans-
Recently separated is up to one year.
I certify that the information provided above is true and complete to the best of my ability and I understand and agree that any misinterpretation or omission on this application or related papers, or made during an oral interview may result in refusal of employment or be considered as grounds for dismissal.:
* [Please Initial]:
Parker Home may make an investigation of my history and may verify all data provided in this application, related papers or an oral interview. I allow such investigation and release from liability, Parker Home/ or any person or company giving or refusing such information.:
* [Please Initial]:
I understand that this application is not, and is not intended to be contract of employment; and that, if hired, my employment is 'at-will', for no definite period and may be ended at any time without prior notice, without liability for wages, salary or any benefits except those earned up to the date of separation. if employed by parker, I agree to undergo medical examinations at any time at the option of Parker. I also understand and agree that I will abide by Parker's rules and regulations. I read, understand and agree to the above.:
* [Please Initial]:
*
Signature:
Date:
Date and time
Now
*
Security Code:
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