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Employment Application for Gracedale Nursing Home

Federal and state laws prohibit discrimination in employment practices because of race, color, religion, age, sex, national origin, handicap or disability. No question on this application is asked for the purpose of limiting or excluding any applicants consideration for employment (because of his or her race, color, religion, age, sex, national origin, handicap or disability).

	Date
	Personal Data
	First Name
	Middle Name
	Last Name
	Address
	City		State
	Zip		County
	Telephone
	Social Security Number
	Are you 17 years of age or older? Yes No
	Are you a U.S. Veteran? Yes No
	Branch of Service
	Type of Discharge
	Dates of Service From To
	Have you ever been employed by Northampton County? Yes No
	Dates of Employment From To
	Referral Source: Advertisement Friend Relative Other
	Have you ever pleaded guilty or have been convicted of a felony or misdemeanor? Yes No
	If so explain:
	In case of an emergency, please notify:
	Relationship: Phone:
	Address:

	*Employment Desired:*
	Position
	Full Time Part Time
	Date Available
	Are you currently employed? Yes No
	May we inquire with your present employer? Yes No

	Education
	High School Name
	Location
	Did you graduate? Yes No

	Undergraduate/College Name
	Location
	Did you graduate? Yes No
	Degree

	Graduate/Professional Name
	Location
	Did you graduate? Yes No
	Degree

	Specialized training, apprenticeship, skills and extra-curricular activities:


	Describe any honors you have received:


	State any additional information you feel may be helpful to us in considering your application:


	*Employment History*
	Employer
	Address
	Employed: From To
	Position
	Salary
	Supervisors Name
	Reason for Leaving

	Employer
	Address
	Employed: From To
	Position
	Salary
	Supervisors Name
	Reason for Leaving

	Employer
	Address
	Employed: From To
	Position
	Salary
	Supervisors Name
	Reason for Leaving

	Employer
	Address
	Employed: From To
	Position
	Salary
	Supervisors Name
	Reason for Leaving

	*Personal References*
	Name
	Address
	Phone Number
	Occupation

	Name
	Address
	Phone Number
	Occupation

	Name
	Address
	Phone Number
	Occupation