Employment Application Form

Applicant Information

Last Name *

Date

First Name *

M.I.

Address *

City *

State

Zip *

Email *

Phone Number

Date Available

Social Security No.

Desired Salary

Position Applying for

Are you a citizen of the United States?

Yes

No

If no, are you authorized to work in the U.S.?

Yes

No

Have you ever worked for this company?

Yes

No

If so, when?

Have you ever been convicted of a felony?

Yes

No

If yes, explain

Education

High School

Address

From

To

Did you graduate?

Yes

No

Degree

College

Address

From

To

Did you graduate?

Yes

No

Degree

Other

Address

From

To

Did you graduate?

Yes

No

Degree

References

Please list three professional references.

Full Name

Relationship

Company

Phone

Address

Full Name

Relationship

Company

Phone

Address

Full Name

Relationship

Company

Phone

Address

Previous Employment

Company 1

Company

Phone

Address

Supervisor

Job Title

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

No

Company 2

Company

Phone

Address

Supervisor

Job Title

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

No

Company 3

Company

Phone

Address

Supervisor

Job Title

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

No

Military Service

Branch

From

To

Rank at Discharge

Type of Discharge

If other than honorable, explain

Next of kin

Last Name

First Name

M.I.

Address

City

State

Zip

Hours Desired

40/WK

<40/WK

On call

Any

Shifts Available

Days

Evenings

Nights

Any

Days Available
Sun Mon Tues Wed Thu Fri Sat

Professional Licensure

Type

Number

Type

Expiration

Current States

Expiration

Current States

Applicant Declaration

Are you 16 or older?

Yes

No

Have you ever been excluded from the Medicare or Medicaid program for conduct that would constitute a misdemeanor, gross misdemeanor or a felony under the law?

Yes

No

If yes, please explain:

Have you ever been disciplined by professional or state ethics or licensing board?

Yes

No

If yes, please explain:

Handicapped

Investigation required by local, state, or federal laws. I understand that if I am hired by Adonis College of Nursing my employment will be for an indefinite period of time and will be "at will" which means that either Adonis College of Nursingor I may terminate the employment relationship at anytime and for any reason or no reason.

I further understand that, if hired, my at-will employment status may only be changed in written contract signed by the management of Adonis College of Nursing and that no representative of Adonis College of Nursing has the authority to make oral promise to me concerning my employment. Finally, I also understand that Adonis College of Nursing may adopt, from time to time, policies or handbooks dealing with benefits and other terms or conditions of employment. These policies or handbooks do not constitute a contract of employment between Adonis College of Nursing and me. Adonis College of Nursing reserves the right to change or discontinue these policies and /or handbooks at any time with or without notice to me. Adonis College of Nursing. strives to provide a safe, healthy and productive work environment and supports a smoke free, alcohol-free work environment.

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature

Date