ࡱ > b d a RX bjbj 4^ t t | ^ * ! ! ! ) ) ) ) ) ) ) $ {- -0 \ ) u ! ! ! ! ! ) _* +# +# +# ! ) +# ! ) +# +# : ' T ( @ꝩ ! <( ) u* 0 * F( R 0 U" 0 ( ( 0 ( ! ! +# ! ! ! ! ! ) ) +# ! ! ! * ! ! ! ! 0 ! ! ! ! ! ! ! ! ! t : St. Joseph's Nursing Home 1222 Tugwell Dr. Catonsville, MD 21228 (410) 747-0026 Application for Employment Application date: It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race age color sex religion national origin or other protected classification. Name Last First Middle Maiden Name Address Number Street City State Zip Code Email Address: ________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S o c i a l S e c u r i t y N u m b e r H o m e P h o n e C e l l P h o n e I n c a s e o f e m e r g e n c y n o t i f y : N a m e A d d r e s s T e l e p h o n e N u m b e r A r e y o u o v e r 1 8 y e a r s o l d ? % y e s % n o A r e y o u a U S c i t i z e n o r o t h e r w i s e a u t h o r i z e d t o w o r k i n t h e U S o n a n u n r e s t r i c t e d b a s i s ? % y e s % n o S h i f t p r e f e r r e d % p a r t t i m e % f u l l - t i m e H o w d i d y o u l e a r n o f t h i s o p e n i n g ? ( n e w s p a p e r , a d , f r i e n d ) H a v e y o u w o r k e d h e r e b e f o r e % y e s % n o I f y e s , w h e n A r e t h e r e a n y h o u r s , s h i f t s o r d a y s t h a t y o u c a n n o t o r w i l l n o t w o r k ? H a v e y o u e v e r b e e n c o n v i c t e d o f a f e l o n y ? % y e s % n o ( c o n v i c t i o n w i l l n o t n e c e s s a r i l y d i s q u a l i f y a n a p p l i c a n t f o r e m p l o y m e n t . I f y e s , d e s c r i b e c o n d i t i o n s : F o r n u r s i n g a s s i s t a n c e o n l y : D o y o u h o l d a M a r y l a n d G e r i a t r i c A s s i s t a n c e C e r t i f i c a t e % y e s % n o F o r R N , L P N , G N A , C M A : M a r y l a n d R e g i s t r y - C e r t i f i c a t i o n N u m b e r N a m e a n d L o c a t i o n o f s c h o o l Y e a r G r a d u a t e d M a j o r D i p l o m a / D e g r e e G r a d e S c h o o l H i g h S c h o o l C o l l e g e / U n i v . G r a d u a t e S c h o o l I n addition to your work history (reverse side), what other experiences skills or qualifications do you have? (They need not be related to the job for which you are applying.) Position Applied for 1. _______________________________ 2. ___________________________________ Wage or salary desired? $ ___________________________ When can you start? _____________________ Employment history May we contact your present employer % y e s % n o P r e s e n t / M o s t R e c e n t E m p l o y e r : A d d r e s s C i t y Z i p C o d e T e l e p h o n e N u m b e r D a t e S t a r t e d S t a r t i n g S a l a r y S t a r t i n g P o s i t i o n $ P e r D a t e L e f t S a l a r y o n L e a v i n g P o s i t i o n o n L e a v i n g $ P e r N a m e and Title of Supervisor Description of Duties Reason for Leaving Previous Employer: Address City Zip code Telephone Number Date Started Starting Salary Starting Position $ Per Date Left Salary on Leaving Position on Leaving $ Per Name and Title of Supervisor Description of Duties Reason for Leaving Previous Employer: Address City Zip Code Telephone Number Date Started Starting Salary Starting Position $ Per Date Left Salary on Leaving Position on Leaving $ Per Name and Title of Supervisor Description of Duties Reason for Leaving Important please read carefully. I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that the misrepresentation or omission of facts called for in this application is cause for immediate dismissal. I authorize St. Joseph's Nursing H P Q | } Ѻu^uGu2 (h- h 5B* CJ OJ QJ aJ ph -h- h,: 0J4 B* CJ OJ QJ ^J aJ ph -h- h 0J4 B* CJ OJ QJ ^J aJ ph -h- h3^ 0J4 B* CJ OJ QJ ^J aJ ph ,h- h,: 0J4 5B* CJ OJ QJ aJ ph ,h)x h,: 0J4 5B* CJ OJ QJ aJ ph ,h)x h3^ 0J4 5B* CJ OJ QJ aJ ph h- h CJ aJ h- h CJ aJ h)x hTj 5CJ aJ h)x h 5CJ aJ + A P Q } f g m < @ 6 $ gd 7 x ]gd~ 6 gd