APPLICATION FOR EMPLOYMENT

(Please Print Clearly)

 

Continuum  Corporate Office for:

Clover Manor Inc._____, Gorham House_____, Sentry Hill_____, Harbor Home_____

(Please indicate which facility this application is for)

 

        Confidential

­­­                                                                                                      Date of                                            Date

                                                                                                                                               Application___________________ Available__________________

Name___________________________________________________________________________                                                        Social

                                Last                                         First                                         Middle                                                           Security

                                                                                                                                                                                                 Number____________________

 

Permanent Address___________________________________________________________________________________________Phone Number_______________

                                                Street                                   City                         State                      Zip Code

Permanent Address

(If different than

Present address)___________________________________________________________________­­­___________________________Phone Number_______________

                                            Street                       City                          State                     Zip Code

 

If you cannot be reached at above phone number, where may we contact  you?  Name of Person______________________________Phone Number________________

 

 

Type of Work Desired	Shift	Salary
First Choice
Second Choice
Third Choice

Will You Accept Employment of:   oFull Time?   oPart Time?   oTemporary?

Are You 18 Yrs. of Age  or Older?           oYes                oNo

Are You Employed Now?           oYes            oNo

May We Contact Your Present Employer?     oYes              oNo

How Did You

Learn of This

Circle Highest                          8     9    10    11    12                               Scholastic

Grade completed                       13   14   15   16                                      Honors Received:________________________________________________

 

	Name of School	Location	Courses Taken	Completed	Degree/Certificate
High School
College
Vocational or business School
Professional Education
Laboratory or X-ray Training

                                               

Member of

Professional Organizations_________________________________________________________________________________________________________________

 

Honors received, Volunteer Services, or Community

Service or Other Qualifications You Have Which

Apply To The Position You Are Seeking______________________________________________________________________________________________________

 

Professional Licenses and/or Certifications

Type	Organization or State Issued	Date Issued	Number	Verif.

 

List current (or most recent) employer first and all others in reverse chronological order.

Company Name	Date Employed                       From                               To
Address (Street, City, State, Zip Code)	Phone                       Starting Salary     Ending Salary                                  $                            $
Position Title	Immediate Supervisor’s Name & Title
Job Description & Responsibilities
May we contact references?
Company Name	Date Employed                       From                               To
Address (Street, City, State, Zip Code)	Phone                       Starting Salary     Ending Salary                                  $                            $
Position Title	Immediate Supervisor’s Name & Title
Job Description & Responsibilities
May we contact references?
Company Name	Date Employed                       From                               To
Address (Street, City, State, Zip Code)	Phone                       Starting Salary     Ending Salary                                  $                            $
Position Title	Immediate Supervisor’s Name & Title
Job Description & Responsibilities
May we contact references?
Company Name	Date Employed                       From                               To
Address (Street, City, State, Zip Code)	Phone                       Starting Salary     Ending Salary                                  $                            $
Position Title	Immediate Supervisor’s Name & Title
Job Description & Responsibilities
May we contact references?

 

 

 REFERENCES  List three References Who Are Not Relatives

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you realize that due to the nature of the services we provide, an exceptional record of attendance, promptness and dependability is required of all Continuum employees?  ____Yes  ____No

 

Are you able to perform the essential functions of the position for which you are applying? ____Yes  ____No    If no, please explain:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

 

Are special accommodations needed?  ____Yes  ____No      If yes, please explain:_________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

 

Have you ever been convicted of a crime other than a traffic violation?  ____Yes  ____No   If yes, when, where and for what?_______

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

 

Have you ever been excluded from participating in any state or federal health care programs including Medicare or Medicaid?

____Yes  ____No

 

This section to be completed by Licensed Professionals only

 

 

Please check areas in which you have experience ____ICU/CCU  ____ER  ____RR  ____OR  Med/Surg 

____Geriatrics  ____OB  ____Pediatrics  ____Hospice  _____Rehab  _____Home Health

 

Have you ever been/or are you currently licensed/registered in any other states? ____Yes  ____No.

If yes, which states:____________________________________________________ When:________________________

And under what name(s):_____________________________________________________________________________

Are you registered in Maine? ____Yes  ____No                        License#_____________________________________________

Expiration Date:___________________________      If no, have you applied? ____Yes  ____No   Date:____________

Any restrictions on license?  _____Yes  _____ No

 

This section to be completed by Nurse’s Aides/PCA/HHA

 

Please check certification you have:  _____CNA  _____PCA  _____HHA   Certification Date:_____________________________

 

Agency where certified:________________________________________________________________________________________

 

 

Employment Understanding (Please read and sign)

 

Completion of this Application does not constitute an Employment Contract

  

This institution does not discriminate in hiring on the basis of race, color, sex, citizenship, national origin, ancestry, sexual orientation, Vietnam era veteran status, or on the basis of age, physical or mental disability unrelated to ability to perform the work required.  No question on this application is intended to secure information to be used for such discrimination.

 

I voluntarily give this institution the right to make a thorough investigation of my past employment, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information.

 

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause.  I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

 

I authorize Continuum to check any or all references listed on Page 2.

 

If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.

 

It is the ongoing and continuous obligation of all employees of Continuum to alert Continuum’s Human Resource Department of any conviction or finding that would disqualify them from continued employment with Continuum under state or federal law.

 

_________________________________________________________________    _________________

Applicant’s Signature                                                                                                    Date