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Employment Application
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What position are you applying for?
*
STNA
LPN
RN
Housekeeping
Laundry
Maintenance
Cook
Dietary Aide
Activities
OT
COTA
Speech Therapist
Name
*
First
Last
Social Security Number
*
Home Address
*
City, State, Zip Code
*
Phone #
*
Email
*
Are you legally allowed to work?
*
Yes
No
Emergency Contact
Emergency Phone
Citizenship
License or Registration Number (if applicable)
Type of Employment Desired
*
Full Time
Part Time
PRN
Temporary
Summer
Shift Preference
*
Day
Evening
Night
Any
Can you Work Anytime? Yes / No If not, Please Explain
*
Are You Willing to Work Weekends?
*
Yes
No
How did you hear about us?
*
Why do you want to join our team?
*
Have you ever worked for Anderson Healthcare, Ltd. or for Aklin, Inc.? Yes / No (If yes, Where, When & What was your reason for leaving?)
*
Do you have a relative working here? Yes / No (If yes, state identity and relationship)
Name of Highschool Attended(if applicable)
High school Years/Grade
High school graduate?
Yes
No
Name of College Attended(if applicable)
College Years/Grade
College Graduate?
Yes
No
Name of Employer #1
Phone Number
Address
Worked There (Month & Year) From - To
Name of Supervisor
Hourly Pay
What was your job title?
Job description
Name of Employer #2
Phone Number
Address
Worked There (Month & Year) From - To
Name of Supervisor
Hourly Pay
What was your job title?
Job description
Name of Employer #3
Phone Number
Address
Worked There (Month & Year) From - To
Name of Supervisor
Hourly Pay
What was your job title?
Job Description
Name of Employer #4
Phone Number
Address
Worked There (Month & Year) From - To
Name of Supervisor
Hourly Pay
What was your job title?
Job Description
Have you missed any work in the last two (2) years?
*
Yes
No
If so, please state the period of absence and the reason for the absence
Have you ever been refused a bond or had a bond cancelled?
Yes
No
If yes, Specify
Have you ever been convicted of a crime?
*
Yes
No
If yes, Specify
Have you resided in Ohio uninterupted for the immediate five years?
Yes
No
If No, List all places you have lived
The position you are applying for may involve physical activity such as lifting or transferring. Can you perform the essential functions of your job with or without reasonable accommodation?
Is any additional information relative to change of name, use of an assumed name or nickname necessary to enable a check of records?
Yes
No
If yes, please explain
Have you ever been dismissed or forced to resign from any employment?
Yes
No
If yes, please explain
Except for vacations and holidays, how many days were you absent during the past year?
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