Employment - Tranquility Manor

Application for Employment

We are an equal opportunity employer and uphold the principles of Equal Opportunity Employment. It is our policy to provide employment compensation and other benefits related to employment based on qualifications and performance without regard to race. color, religion, national orgin, age, sex, veteran status or disability, or any other basis prohibited by Fedral or State law.

As an Equal Opportunity Employer we intend to comply fully with all Federal and State laws and the information requested on this application will not be used for any purpose prohibited by law.
Disabled applicants may request any needed accomodation.

This application is intended to allow you the applicant to provide our organization with the information and data so that your suitability and qualifications can be fairly determined for the position for which you are applying.

Please complete this application and answer all questions completely.

Name

First Name

Last Name

Social Security Number

Phone

Address

City

State

Zip Code

Have you been previously employed by our facility?

Yes

No

How did you learn of the position for which you are applying?

Shift Preferences

FREQUENCY

Full Time

Part Time

Date Available to Start

Enter the date you can start working

Salary Requested

PERSONAL HISTORY

Are you a United States citizen or do you have an entry permit which allows you to lawfully work in the U.S.?

Yes

No

If applicable, List your VISA type:

Immigration Number

Are you at least 18 years of age?

Yes

No

Are you ineligible to be employed with a Virginia licensed Health Care entity as a result of being found guilty by a court of law for abusing, neglecting or mistreating individuals in a health care related setting?

Yes

No

If “Yes” please explain:

Are you able to perform all of the duties required by the position for which you are applying, without endangering yourself or compromising the safety, health or welfare of the Residents/Clients od other Staff members?

Yes

No

If “No” please explain

EDUCATION

School Name and Location

Type of School

Dates

Degree or Course of Study

EMPLOYMENT HISTORY

Please give accurate and complete information. Start with present or most recent employer.

Most Recent Employer Name and Address, City, State and Zip

Phone

Job Title

Supervisor’s name

Description of Responsibilities

Reason for leaving

May we contact this employer?

Yes

No

Most Recent Employer Name and Address, City, State and Zip

Phone

Job Title

Supervisor’s name

Description of Responsibilities

Reason for leaving

May we contact this employer?

Yes

Option 2

LICENSURE /CERTIFICATION /REGISTRATION

Please list any licenses certification registration you currently have

List any special skills or qualifications which you possess and feel are relevant to healthcare and the position for which you are applying

MILITARY SERVICE

Branch of Service

What was your MOS/ Duties

Dates of Service

Rank/Grade

Honorable Dischage

Yes

No

REFERENCES

List Reference Name/ Email Address/ Phone Number