Employment Application
Please complete the form, sign, and submit. A PDF copy will be emailed to HR.
Note:
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General Information
Last Name
First Name
Middle Initial
Position Applying For
Date
How were you referred to us?
Email Address
Address
City
State
Zip
Phone
Cell Phone
Social Security # (optional)
Legal right to work in the U.S.?
-- Select --
Yes
No
Driver’s License # (if applicable)
DL State
Date available to start
Rate of expected pay
Full name (as you want it on the PDF)
Education
High School
City/State
College / Vocational
City/State
Other / Certifications / Notes
Professional References (up to 3)
Reference 1
Name
Relationship
Phone
Reference 2
Name
Relationship
Phone
Reference 3
Name
Relationship
Phone
Previous Employment (most recent first)
Employer 1
From
To
Position(s) held
Company
Phone
Address
Supervisor
Title
May we contact this employer?
-- Select --
Yes
No
Responsibilities
Reason for leaving
Employer 2
From
To
Position(s) held
Company
Phone
Address
Supervisor
Title
May we contact this employer?
-- Select --
Yes
No
Responsibilities
Reason for leaving
Employer 3
From
To
Position(s) held
Company
Phone
Address
Supervisor
Title
May we contact this employer?
-- Select --
Yes
No
Responsibilities
Reason for leaving
License / Certification (optional)
Type
Number
County
Issue date
Expiration date
Authorization
I,
, hereby authorize Kit Carson Nursing and Rehabilitation and/or its agents to make an independent investigation of my background, references, character, past employment, education, credit history, adult criminal or police records, and motor vehicle records to confirm the information in my application.
I release Kit Carson Nursing and Rehabilitation and its agents and any person or entity that provides information pursuant to this authorization from any and all liabilities, claims, or lawsuits regarding the information obtained.
Full Name (Printed)
Date
Signature (draw below)
Clear
Undo
Human check
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