Employment Application Please enable JavaScript in your browser to complete this form.What position are you applying for? *STNALPNRNHousekeepingLaundryMaintenanceCookDietary AideActivitiesOTCOTASpeech TherapistName *FirstLastSocial Security Number *Home Address *City, State, Zip Code *Phone # *Email *Are you legally allowed to work? *YesNoEmergency ContactEmergency PhoneCitizenshipLicense or Registration Number (if applicable)Type of Employment Desired *Full TimePart TimePRNTemporarySummerShift Preference *DayEveningNightAnyCan you Work Anytime? Yes / No If not, Please Explain *Are You Willing to Work Weekends? *YesNoHow 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/GradeHigh school graduate?YesNoName of College Attended(if applicable)College Years/GradeCollege Graduate?YesNoName of Employer #1Phone NumberAddressWorked There (Month & Year) From - ToName of SupervisorHourly PayWhat was your job title?Job descriptionName of Employer #2Phone NumberAddressWorked There (Month & Year) From - ToName of SupervisorHourly PayWhat was your job title?Job descriptionName of Employer #3Phone NumberAddressWorked There (Month & Year) From - ToName of SupervisorHourly PayWhat was your job title?Job DescriptionName of Employer #4Phone NumberAddressWorked There (Month & Year) From - ToName of SupervisorHourly PayWhat was your job title?Job DescriptionHave you missed any work in the last two (2) years? *YesNoIf so, please state the period of absence and the reason for the absenceHave you ever been refused a bond or had a bond cancelled? YesNoIf yes, SpecifyHave you ever been convicted of a crime? *YesNoIf yes, SpecifyHave you resided in Ohio uninterupted for the immediate five years?YesNoIf No, List all places you have livedThe 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?YesNoIf yes, please explainHave you ever been dismissed or forced to resign from any employment?YesNoIf yes, please explainExcept for vacations and holidays, how many days were you absent during the past year?CommentsEmailSubmit
