Aloha Nursing Rehab Centre

EMPLOYMENT APPLICATION

Aloha Nursing Rehab Centre is an equal opportunity employer. Applicants are considered for positions without discrimination against race, color, religion, national origin, ancestry, sex, sexual orientation, age, disability, genetic information, marital status, arrest and court record, credit history, domestic or sexual violence, victim status, veteran or military status, citizenship, or any other characteristic protected by federal, state, or local law.

Date	Position you are applying for Full time Part time Oncall

Is there anything that would prevent you from performing in a safe manner the activities involved in the position for which you are seeking employment?
Yes No

Have you ever been employed by Aloha Nursing Rehab Centre? Yes No If so, when?

Are you authorized to work in the United States of America? Yes No

GENERAL INFORMATION:

Name

Address

Phone

City

State

Zip

Employment Record: STARTING WITH PRESENT or MOST RECENT, list all previous employers. Include self-employment, military service, summer, and part-time jobs. Please attach additional sheets if necessary, following the same format.

Name and Address of Current or Former Employer

Dates Employed

Position & Duties

Reason for Leaving

Name Address State Zip	Phone City
Supervisor's Name	Title
Job Skills and qualifications - summarize any special skills, certifications...

From Mo./Yr.

To Mo./Yr.

Position Held

Duties

Name and Address of Current or Former Employer

Dates Employed

Position & Duties

Reason for Leaving

Name Address State Zip	Phone City
Supervisor's Name	Title
Job Skills and qualifications - summarize any special skills, certifications...

From Mo./Yr.

To Mo./Yr.

Position Held

Duties

Name and Address of Current or Former Employer

Dates Employed

Position & Duties

Reason for Leaving

Name Address State Zip	Phone City
Supervisor's Name	Title
Job Skills and qualifications - summarize any special skills, certifications...

From Mo./Yr.

To Mo./Yr.

Position Held

Duties

May we contact your current employer(s)? Yes No

Do you know anyone presently working for our company? Yes No If so, who?

Have you ever been employed in a long term care facility? Yes No If so, which?
Dates?

NOTE: It is the policy of this Company to hire only U.S. citizens and aliens who are authorized to work in this country. (As a condition of employment, you will be required to produce original documents establishing your identity and authorization to work, and to complete the U.S. Immigration and Naturalization Service’s Form I-9.)

References: (Not Relatives)

Name	Occupation
Address	Telephone No.

Name	Occupation
Address	Telephone No.

Education

Highest Level Of Education Achieved	Date Achieved
Academic Institution	City State
Degree or Certificate Obtained	Other Licences, Certificates or Training (relating to the position you are applying for)

By signing below, I certify that all statements made on this application are true and complete to the best of my knowledge. I understand that my application will not be considered if it is incomplete. Further, I understand that any misrepresentation or omission made herein, when discovered, may subject me to discharge. I authorize the Company to investigate my work history, education, character, reputation, and background as it deems necessary for purposes of considering my application for employment. In exchange for the Company’s consideration of my application for employment, I hereby release the Company and all providers of information (including, but not limited to, any of my former employer, educational institutions attended, and personal references) from all liability relating to or arising out of any inquiry by the Company regarding my work history, education, character, reputation and background.

After an offer of employment is made, but before employment duties begin, applicants may be required to undergo a physical or medical examination (or drug test) at Company expenses and by a Company-chosen physician, with the offer of employment conditioned on the result of such examination. Employees, at any time during the course of their employment, may be required to undergo a medical (or drug) examination at Company expenses and by a Company-chosen physician. I agree to provide the Company with any authorization or release which may be required for a per-employment medical examination drug test.

The application is not a contract of employment and cannot create a contract of employment for any specific period. I understand that if I am employed, my employment is “at will” and can be terminated at any time, either by myself or the Company, with or without cause or reason and with or without notice. Only the Executive Director is authorized to modify the Company’s at-will employment policy or enter into an agreement contrary to this policy. Any such modification must be in writing and signed by the employee and the Executive Director.

This application will only be considered for three months. I understand that if I have not been hired within three months of completing this application, and I still wish you be considered for employment, I must complete another application.

How did you hear about us?

Person you were referred by

Pre-Employment Drug Screen

Notification of Pre-Employment Drug Testing

This is to inform you that Aloha Nursing Rehab Centre conducts pre-employment drug testing for all applicants who receive a conditional offer of employment. By signing this notification, you are acknowledging that:

Aloha Nursing Rehab Centre conducts pre-employment drug testing upon making a conditional offer of employment.
The drug test must be completed within 24 hours upon receipt a conditional offer of employment.
The drug test must be completed prior to starting any work with Aloha Nursing Rehab Centre.
Failure to complete the drug test will result in the withdrawal of the conditional offer of employment.
Refusal to complete the drug test will result in the withdrawal of the conditional offer of employment.
A positive result for drug use will result in the withdrawal of the conditional offer of employment.

Applicant Signature

Click the 'Apply signature' button to save your signature to the application.