Personnel application * We consider applicants for all positions without regard to race, color, religion, national origin, or any other legally protected status Step 1 of 5 20% Personal InformationName* First Middle Last Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneCell PhoneCredentials RN LPN CNA CHHA Are you 18 years of age or older?YesNoAre you eligible to work in the United States?YesNoOther names under which you have attended school or been employed?YesNoList other name*Do you have access to a working computer with internet service?YesNoDo you have an e-mail address?YesNoIf yes, what is it* Are you currently employed?YesNoIf yes, name of company:*Do you have adequate transportation to get to work on time each day?YesNoDo you have a valid driver’s license?YesNoIf yes, state of issuance, license # and expiration date:*Are you currently on” lay-off” status and subject to recall?YesNoHave you ever been convicted of a crime?YesNoDo you have an FBI clearance?YesNoIf yes, provide date:*Do you have a child abuse clearance?YesNoIf yes, provide date:*If yes, explain:*Have you ever been convicted of a felony?YesNoIf yes, explain:*Do you possess any physical limitations that would interfere with your job performance?YesNoIf 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by the State Board of Nursing in this state or any other state?YesNoIf yes, explain:*Has your Nursing license ever been revoked, either temporarily or permanently, by the state Board of Nursing of this state or any other state?YesNoIf yes, explain:*Are you currently excluded from participating in any federally funded health care program including Medicare and Medicaid?YesNoIf yes, explain:*Are you aware of any potential exclusion from a federally funded health program?YesNoIf yes, explain:*Is your license currently under review for any reason?YesNoIf yes, explain:* EducationHigh SchoolCity/StateDid you graduate?YesNoDegree receivedMajorIf No, # of years left to graduate*If Yes, date of Graduation*GEDCity/StateDid you graduate?YesNoDegree receivedMajorIf No, # of years left to graduate*If Yes, date of Graduation*Other SchoolCity/StateDid you graduate?YesNoDegree receivedMajorIf No, # of years left to graduate*If Yes, date of Graduation*CollegeCity/StateDid you graduate?YesNoDegree receivedMajorIf 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/StateLicense/ Certificate #SKILLS: Please list technical skills, clerical skills, trade skills, etc., relevant to this position. WORK EXPERIENCEPlease detail your entire work history. Begin with your current or most recent employer.You may attach resume in place of filling in this sectionUpload resume file hereDates Employed (most recent position)Employer’s Name:Employer’s Address:Title:PositionFull timePart timeSupervisor’s Name, TitleSupervisor’s PhoneMay we contact?YesNoPrimary duties:Reason for Leaving:Dates Employed (most recent position)Employer’s Name:Employer’s Address:Title:PositionFull timePart timeSupervisor’s Name, TitleSupervisor’s PhoneMay we contact?YesNoPrimary duties:Reason for Leaving:Dates Employed (most recent position)Employer’s Name:Employer’s Address:Title:PositionFull timePart timeSupervisor’s Name, TitleSupervisor’s PhoneMay we contact?YesNoPrimary duties:Reason for Leaving:Dates Employed (most recent position)Employer’s Name:Employer’s Address:Title:PositionFull timePart timeSupervisor’s Name, TitleSupervisor’s PhoneMay we contact?YesNoPrimary duties:Reason for Leaving: REFERENCES: NO personal references please..(3 prior professional references with 1 supervisor/manager related reference required)Reference NameReference PhoneRelationshipAddress Street Address City State / Province / Region ZIP / Postal Code Reference NameReference PhoneRelationshipAddress Street Address City State / Province / Region ZIP / Postal Code Reference NameReference PhoneRelationshipAddress Street Address City State / Province / Region ZIP / Postal Code Applicant’s StatementThe 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.Type your name to sign
