Application for Employment

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Applying for the Post of RN/LPN

* Mandatory Fields

Personal Information

First Name :*

Middle Name :

Last Name :*

Social Security #:*

Present Address

Street :*

PO Box :

City :*

State :*

Zip :*

Telephone # :*

Permanent Address

Same as present address

Street :

PO Box :

City :

State :

Zip :

Telephone # :

Type of Employment Desired :

Specify days and hours :

Preferred Shift :

1st 2nd 3rd

List Volunteer or Community Service Positions (work) which you feel are related to the position for which you are applying.

Briefly state any special skills or qualifications you have which you feel are related to the position for which you are applying.

Were you previously employed by us? Yes No

If yes, When?

List any friends or relatives working for us

Name :

Relationship :

Name :

Relationship :

Have you ever been convicted of a crime? Yes No
(note: conviction of a criminal offense will not necessarily preclude your employment.)

If yes, describe in full

If your application is considered favorably, on what date will you be available for work?

Person to be notified in case of accident or emergency

Name :

Relationship :

Telephone # :

Address :

Record of Education

School

Name & Address of School

Course of Study / Major Field

Select Last Year Completed

Did You Graduate?

List Diploma / Degree

High School *

Yes No

College *

Yes No

Other(specify)

Yes No

Military Service Record

Were you in U.S. Armed Forces?

Yes No

If yes, what branch?

Dates of Duty :

From To

Rank at Discharge :

List duties in the service including special training:

Personal References (Do Not Include Relatives or Former Employers) *

Name and Occupation	Address	Phone #

Employment Record (List All Present and Past Positions, Beginning with Most Recent)

Name & Address of Company & Type of business	From Mon Year	To Mon Year	Describe in detail the work you did	Weekly Starting Salary	Weekly Ending Salary	Name of Supervisor	Number of Supervisor

Have you ever been bonded? Yes No

If yes, on what jobs?

May we contact the employers list above? Yes No

If not, indicate which one(s) you do not wish us to contact?

Please Read and Sign (Electronically) Below

Pleasant View Home, Inc. has a policy of pre-employment screening for the use of illegal drugs and substance abuse. All offers of employment are contingent on submission to this company's drug/alcohol screening procedure. Any contingent offer of employment will be withdrawn if the applicant tests positive for any illegal drugs or substance abuse.

I understand that according to federal law all individuals who are hired must, as a condition of employment, produce certain documentation to verify their identity and U.S. citizen status or, if not, their legal authorization to work in the U.S. As a consequence, I understand that any offer of employment would be contingent on my ability to produce the required documentation within the time period required by law.

I hereby, authorize Pleasant View Home, Inc. to make an investigation of my personal history and former employers, pertinent to my employment. I understand that, I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of any such investigative record that is made.

I hereby, certify that the information set forth in my application for employment is true and complete. I understand that false or incomplete statements on this application shall be considered grounds for disqualification for employment or sufficient cause for dismissal.

By electronically filling out your name in the below box, you hereby agree to have read and agree to follow the above disclosed agreement by Pleasant View Home.

Date : 09-05-2010

Email :*

Signature :*