Personnel application

* We consider applicants for all positions without regard to race, color, religion, national origin, or any other legally protected status

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Personal Information

Name*

First Middle Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Home Phone

Work Phone

Cell Phone

Credentials

LPN

CNA

CHHA

GPN

Are you 18 years of age or older?

Yes

Are you eligible to work in the United States?

Yes

Have you resided outside of Pennsylvania within the last 2 years?

Yes

Other names under which you have attended school or been employed?

Yes

List other name*

Do you have access to a working computer with internet service?

Yes

Do you have an e-mail address?

Yes

If yes, what is it*

Are you currently employed?

Yes

If yes, name of company:*

Do you have adequate transportation to get to work on time each day?

Yes

Do you have a valid driver’s license?

Yes

If yes, state of issuance, license # and expiration date:*

Are you currently on” lay-off” status and subject to recall?

Yes

Have you ever been convicted of a crime?

Yes

Do you have an FBI clearance?

Yes

If yes, provide date:*

Do you have a child abuse clearance?

Yes

If yes, provide date:*

If yes, explain:*

Have you ever been convicted of a felony?

Yes

If yes, explain:*

Do you possess any physical limitations that would interfere with your job performance?

Yes

If yes, explain:*

What hours and days are you looking for?

What is your expected hourly rate?

Have you ever been subject to disciplinary action by the State Board of Nursing in this state or any other state?

Yes

If yes, explain:*

Has your Nursing license ever been revoked, either temporarily or permanently, by the state Board of Nursing of this state or any other state?

Yes

If yes, explain:*

Are you currently excluded from participating in any federally funded health care program including Medicare and Medicaid?

Yes

If yes, explain:*

Are you aware of any potential exclusion from a federally funded health program?

Yes

If yes, explain:*

Is your license currently under review for any reason?

Yes

If yes, explain:*

Education

High School

City/State

Did you graduate?

Yes

Degree received

Major

If No, # of years left to graduate*

If Yes, date of Graduation*

GED

City/State

Did you graduate?

Yes

Degree received

Major

If No, # of years left to graduate*

If Yes, date of Graduation*

Other School

City/State

Did you graduate?

Yes

Degree received

Major

If No, # of years left to graduate*

If Yes, date of Graduation*

College

City/State

Did you graduate?

Yes

Degree received

Major

If No, # of years left to graduate*

If Yes, date of Graduation*

Other credentials/ licenses/ professional affiliations, etc., which are relevant to the job(s) for which you are applying:

City/State

License/ Certificate #

SKILLS: Please list technical skills, clerical skills, trade skills, etc., relevant to this position.

WORK EXPERIENCE

Please detail your entire work history. Begin with your current or most recent employer.

You may attach resume in place of filling in this section

Max. file size: 128 MB.

Upload resume file here

Dates Employed (most recent position)

Employer’s Name:

Employer’s Address:

Title:

Position

Full time

Part time

Supervisor’s Name, Title

Supervisor’s Phone

May we contact?

Yes

Primary duties:

Reason for Leaving:

Dates Employed (most recent position)

Employer’s Name:

Employer’s Address:

Title:

Position

Full time

Part time

Supervisor’s Name, Title

Supervisor’s Phone

May we contact?

Yes

Primary duties:

Reason for Leaving:

Dates Employed (most recent position)

Employer’s Name:

Employer’s Address:

Title:

Position

Full time

Part time

Supervisor’s Name, Title

Supervisor’s Phone

May we contact?

Yes

Primary duties:

Reason for Leaving:

Dates Employed (most recent position)

Employer’s Name:

Employer’s Address:

Title:

Position

Full time

Part time

Supervisor’s Name, Title

Supervisor’s Phone

May we contact?

Yes

Primary duties:

Reason for Leaving:

REFERENCES: NO personal references please..

(3 prior professional references with 1 supervisor/manager related reference required)

Reference Name

Reference Phone

Reference Email Address

Relationship

Address

Street Address City State / Province / Region ZIP / Postal Code

Reference Name

Reference Phone

Reference Email Address

Relationship

Address

Street Address City State / Province / Region ZIP / Postal Code

Reference Name

Reference Phone

Reference Email Address

Relationship

Address

Street Address City State / Province / Region ZIP / Postal Code

Applicant’s Statement

The information provided on this Application for Employment is true, correct, and complete. It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or termination from employment if I am subsequently employed. I give Criticare Lancaster, Inc. the right to investigate all references and to secure additional information about me, including criminal background clearance, child abuse clearance, FBI clearance, professional license verification, etc. as deemed necessary and appropriated by the Company for the position(s) for which I am applying. I hereby release from liability, Criticare Lancaster, Inc. and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. Criticare Lancaster, Inc. is an Equal Opportunity Employer.

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