SSL

 

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources department.

Position Applying For:

Date Available To Start

Employment Type:

Preferred Shift

Full Name:

 

 

 

    First   Middle   Last
Street:

 

 
City:   Previous Names Used  
State:

 

 
Zip Code:

 

If you prefer contact by email.

Primary Phone:

Email Address

Alternate Phone:

Professional License No#

 

Social Security Number:

   

Drivers License No#:

State: 

Only Required if Driving is A Job Requirement

If you are under 18, and it is required, can you furnish a work permit?

Yes   No

Are you prevented from becoming employed in this country because of Visa or Immigration Status?  Proof of citizenship or immigration status will be required prior to employment.

Yes  No

Have you ever been employed at Methodist Manor Before?

Yes  No

If Yes   Start Date:   End Date:   Position:

 

Are you capable of meeting the attendance requirements of the position?

Yes  No

Would you be willing to work overtime if it is required?

Yes  No

Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime other than a simple misdemeanor offense relating to motor vehicles and laws of the road under chapter 321 or equivalent provisions, in this state or any other state?

Yes  No

If Yes Explain:

 

Conviction is not necessarily a bar to employment. Each instance and explanation will be considered in relationto the position for which you are applying.

Summarize any training, skills, licenses and/or certificates, that may qualify you as being able to perform job related functions, in the position for which you are applying.

 

Highschool

Years:   

College

Years:  

Other

Years:

Name

Name

Name

City

City

City

State

State

State

Diploma

Yes  No

Major

 Deg

Explain

Current / Last Employer

         Start Date:      End Date

City

 Salary/Wages $
State  Summarize Responsibilities:

Telephone Number

 

Supervisors Name

 Reason For Leaving:

Your Job Title

 

Second / Last Employer

         Start Date:      End Date

City

 Salary/Wages $
State  Summarize Responsibilities:

Telephone Number

 

Supervisors Name

 Reason For Leaving:

Your Job Title

 

Third / Last Employer

         Start Date:      End Date

City

 Salary/Wages $
State  Summarize Responsibilities:

Telephone Number

 

Supervisors Name

 Reason For Leaving:

Your Job Title

 

REFERENCES Name City State Telephone

Please give 3 personal references,

that are not related to you and you
have not previously worked for

How did you hear about the job opportunity at the Methodist Manor?

Attach Resume: