Employment Application

Assisted Living in Peoria, AZ | Nurse's Assisted Living

Employment Application

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Programs, services and employment are equally available to everyone. Please inform the Human Resources Department if you require reasonable accomodation for the application or interview.

How were you referred to us:

Position Applied For:

Full Name:

Address:

City:

State:

Zip:

Phone:

Mobile/Pager/Other:

Email:

Date Available to Start

Social Security Number:

Salary Requirements:

If you are under 18 years of age, can you provide a work permit?

Yes

If no, please explain:

Have you ever worked for this company?

Yes

If yes, when?

Are you legally allowed to work in the United States?

Yes

Type of employment desired:

Full-Time

Part-Time

Temporary

Seasonal

Have you ever pleaded guilty, no contest or been convicted of a crime?

Yes

If yes, give dates and details:

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Answering yes to these questions does not constitute an automatic rejection for employment. Date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be considered.

Driver's license number (if applicable to position):

State:

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Education History

Name & Location of High School:

Did you graduate?

Yes

Name & Location of College:

Years attended:

Degrees completed:

Other Subjects Studied:

Trade, Business or Correspondence School:

Years attended:

Subjects Studied:

Did you graduate:

Yes

Summarize Your Special Skills or Qualifications:

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Previous Employment (begin with most recent position)

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Dates of Employment:

From:

To:

Position(s) Held:

Company Name:

Address:

City:

State:

Zip:

Phone:

Supervisor:

Title:

Responsibilities:

Starting Salary and Title:

Ending Salary and Title:

Reason for Leaving:

May we contact this employer for a reference?

Yes

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Dates of Employment:

From:

To:

Position(s) Held:

Company Name:

Address:

City:

State:

Zip:

Phone:

Supervisor:

Title:

Responsibilities:

Starting Salary and Title:

Ending Salary and Title:

Reason for Leaving:

May we contact this employer for a reference?

Yes

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Dates of Employment:

From:

To:

Position(s) Held:

Company Name:

Address:

City:

State:

Zip:

Phone:

Supervisor:

Title:

Responsibilities:

Starting Salary and Title:

Ending Salary and Title:

Reason for Leaving:

May we contact this employer for a reference?

Yes

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"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment, and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utlization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."

Signature of Applicant (Type Name):

Date:

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This application for employment is sold only for general use throughout the United States. Adams assumes no responsibility and hereby disclaims any liability for the inclusion in this form of any questions or requests for information upon which a violation of local, state, and/or federal law may be based. It is the user's responsibility to ensure that this form's use complies with applicable laws, which change from time to time.

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We are proud to be featured as a top-rated community in Peoria, AZ by Assisted Living Magazine

Nurse's Assisted Living

8249 W Crocus Dr
Peoria , AZ 85381

Phone: (775) 750-7373