CNALPNRN	Certification/License #:	State:
Year you first obtained certification/license:	Expiration Date:  Now

Check all the jobs you are interested in: Food Service AideCookHousekeeperMaintenanceClericalRecreationSupervisorDept. HeadOther
If other, Please explain:

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Check Schedule you can work:Full timePart timeDoesn't matterWeekends okWeekends NOT ok

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Shift Preference:

7am-3pm3pm-11pm11pm-7amOtherDoesn't matter

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Prefer:

Nursing HomesAssisted Living/Adult Day HealthDoesn't matter

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Personal Information

* First Name:				* Last Name:
* Address:				Address (Cont.):
* City:				* State:
				* Zip:
Cell Phone:		( )  -		* Telephone #:	( )  -
* E-mail Address:

Valid NJ driver's license:

YesNo

Over 18 years old?:

YesNo

Salary Expected: 

Start date:  Now

Legally authorized to work in U.S.:

YesNo

Ever worked or attended school under another name:

YesNo

If yes, please provide name:  

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Working for Parker

Have you ever worked for, or volunteered at, Parker Home:

YesNo

If yes, please provide dates and job title or volunteer activity:

Have you filled out an application for Parker Home before:

YesNo

Who Referred You To Parker Home?:  

Are you related to anyone currently employed by Parker Home:

YesNo

If yes, please provide name and relationship:

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Emergency Notification:

Name:
Relationship:
Home Phone:	( )  -
Cell Phone:	( )  -
Work Phone:	( )  -

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To the best of your knowledge, are you physically and mentally able to perform the duties of the position for which you have applied:  YesNo
If no, please explain:

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Military Service

Military Service:

YesNo

Branch:

Military Service Dates:   From:Now To: Now

Honorable Discharge:

YesNo

Please explain:

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Ever been convicted of a crime:

YesNo

If yes, please explain:

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Name, Location of HS, Technical School, College:	Major Subject:	Degree/Certificate:	Completed yes/No:

Your strengths:  

Your weakness:  

Long range goals:  

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[Optional] Do you consider yourself:	Hispanic/Latino Asian Amer.Ind./Alaskan White Native Hawaiian/Pacific Islander Black/African American Two or more Races

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Please provide the following information for the past 10 years.:

Current Employer:
Phone:	( )  -
Your Salary $:
Address:
City:
State:
Zip:
Job Title & Responsibilities:
Supervisor's Name & Title:
Reason for Leaving:
Dates of Employment	From:  Now
	To:  Now

May we contact your current employer for a reference?:

YesNo

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Past Employer 1:		Past Employer 2:
Phone:	( )  -	Phone:	( )  -
Your salary $:		Your Salary $:
Address:		Address:
City:		City:
State:		State:
Zip:		Zip:
Employment Dates:		Employment Dates:
From:	Now	From:	Now
To:	Now	To:	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:

YesNo

If yes, how many more years of work history?:  

If any of them were in health care, please say how many years.:  

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Please print the name, telephone number and relationship of three other references.:

First Name:		First Name:
Last Name:		Last Name:
Phone:	( )  -	Phone:	( )  -
Relationship:		Relationship:

 

First Name:
Last Name:
Phone:	( )  -
Relationship:

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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:   Now

* Security Code: