Employment Application

General Information

Date*

Position Desired*

Last Name*First Name*Middle Initial

Email Address*Home PhoneCell Phone*

Address 1*Address 2City*

State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code*

Are you a U.S. Citizen?*YesNoIf no, are you eligible to work?YesNo

Availability (check all that apply)Full TimePart TimeDaysEveningsWeekendsNightsTemporarySummer

How did you hear about us?*NewspaperEmployeePhone BookOtherIf other, how:

Have you ever been convicted of a felony?*YesNoIf yes, please describe:Are you at least 16 years old?YesNo

Have you been previously employed by Elmhurst Extended Care Center?YesNoIf yes, when:Start date:End date:

Are you registered in a profession?YesNo

If yes:

ProfessionRegistration #

StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingExp. Date

EDUCATION

Name of High SchoolLocation

Years AttendedDid you graduate?YesNo

Highest advanced education:CollegeUniversityVocationalOtherIf other, explain:Name of InstitutionLocation

Did you graduate?YesNoType of degree granted?Years attended

ELMHURST EXTENDED CARE CENTER (EECC) IS AN EQUAL OPPORTUNITY EMPLOYER AND DOES NOT DISCRIMINATE ON THE BASIS OF RACE, CREED, COLOR, SEXUAL ORIENTATION, AGE, NATIONAL ORIGIN, OR HANDICAP. ALL JOB APPLIANTS MAY REQUEST ANY NEEDED ACCOMMODATION OR ASSISTANCE IN ORDER TO COMPLETE THE JOB APPLICATION AND PARTICIPATE IN THE APPLICATION PROCESS.

EMPLOYMENT

Are you currently employed?YesNo

If yes, can we contact your current employer?YesNo

Present/Last Employer

NamePhone NumberSupervisorDATES OF EMPLOYMENTStart DateEnd DateReason for leavingSalaryJob title and duties

2nd to Last Employer

NamePhone NumberSupervisorDATES OF EMPLOYMENTStart DateEnd DateReason for leavingSalaryJob title and duties

3rd to Last Employer

NamePhone NumberSupervisorDATES OF EMPLOYMENTStart DateEnd DateReason for leavingSalaryJob title and duties

Job applicants are advised that the employment relationship with EECC is terminable at will. It is EECC’s policy to check references offered by applicants. It is our objective to obtain information on ability, previous job performance, character, and regulation for the sole purpose of considering you for employment. By signing this document I hereby give EECC permission to request and obtain any such information that will assist in my becoming employed.

REFERENCES

List professional or educational references (no friends or relatives)

REFERENCE ONE

NameAddressTelephoneRelationship

REFERENCE TWO

NameAddressTelephoneRelationship

I verify that all information given on this application for employment is correct to the best of my knowledge. I understand that if any statement herein is found not to be true or if my references are not entirely satisfactory to EECC, I may be denied employment or dismissed without notice if and when discovered. I understand that employment, if offered, is for no definite period. I understand that an offer of employment and my continued employment with EECC are contingent upon satisfactory proof of my authorization to work in the United States. I agree to comply with all facility rules and regulations. I agree to complete a drug test and understand that if the results are unsatisfactory I will be terminated. I understand that a criminal background check will be completed and if any felonies are discovered, offer of employment will be revoked. If I am released for any of these reasons, I will be paid only through the day of release and my employer has the right to cancel any benefits that may have accrued.