Solomons Senior Living

 

Solomons Rehab and Care Center Employment Application

Solomons Rehab and Care Center is an Equal Opportunity Employer. All applicants and employees will be treated equally in conformity with all existing laws. In answering the questions below, if you have any doubts as to the propriety or legality, please contact us for an explanation of the questions. If you still have doubts, do not answer the specific questions.

To assist us in giving you every consideration for employment, please keep us notified of any significant changes to be made on your application. All information will be treated confidentially.

 

Personal Information:

Position Applying For:

Last Name:

First Name:

Middle Name:

Street Address:

City:

State:

Zip Code:

E-mail Address:

Home Phone (including area code):

Cell Phone (including area code):

Work Phone (including include area code):

Social Security last 4 numbers (xxx xx - - - -):

 

Job Preference:

Availability

(Check all that apply):

Full-time Part-time

Occasional Temporary

Date available to start work:

Shift preferred

(Check all that apply):

7:00a - 3:00p 3:00p - 11:00p

11:00p-7:00a Other

 

Education:

High School

Name:

City

State:

Did you graduate?

Yes No

G.E.D. or equivalent?

Yes No

 

College

Name:

City

State:

Did you graduate?

Yes No

Degree(s):

Major:

Hours completed:

List additional training received:

 

Graduate Study

Name:

City

State:

Did you graduate?

Yes No

Degree(s):

Major:

Hours completed:

List additional training received:

 

Technical, Professional or School of Nursing

Name:

City

State:

Did you graduate?

Yes No

Degree(s):

Major:

Hours completed:

List additional training received:

 

Driver's Record

Bring a valid drivers license to your interview.

Driver's License Number:

State Issued:

Expiration Date:

 

Employment History

List below previous employers, starting with the most recent. Please specify any other names.

Current or Most Recent Job

Dates of Employment:

to

Name of employer:

Position or title:

Salary:

Duties

Address:

City:

State:

Phone:

Supervisor:

May we contact this employer?

Yes No

Reason for leaving:

 

Prior Job (if applicable)

Dates of Employment:

to

Name of employer:

Position or title:

Salary:

Duties

Address:

City:

State:

Phone:

Supervisor:

May we contact this employer?

Yes No

Reason for leaving:

 

Prior Job (if applicable)

Dates of Employment:

to

Name of employer:

Position or title:

Salary:

Duties

Address:

City:

State:

Phone:

Supervisor:

May we contact this employer?

Yes No

Reason for leaving:

 

References

Please list two persons who have known you for at least 2 years (not a relative or employers)

Name

Phone

Address

Occupation

 

Criminal Background:

Failure to answer the following information correctly when completing this application is grounds for not hiring or immediate dismissal.

Have you ever been convicted by any court of a crime, other than a minor traffic violation?

Yes No

NOTE: A conviction is not necessarily a bar to employment.

If yes, give date, place, charge, disposition, & rehabilitation activities:

If applying for a position in the nursing department, answer the following:

Have you previously been charged & cleared of prior convictions by the Department of Health?

Never been charged

Cleared

Not been cleared

Have you been convicted by any court of a crime since your last certification renewal?

Yes

No

 

Additional Information:

Are you under 18 (work permit required)?

Yes No

Applicants must be at least 16 years of age to be eligible for employment. Minors (those under 18 years of age) are employed in accordance with applicable child labor laws.

Are you legally eligible for employment in the U.S.?

Yes No

If not a U.S. citizen, does the visa you have permit you to work?

Yes No

Solomons Nursing Center abides by the Immigration Reform & Control Act of 1988 and requires all employees to provide documentation for verification of identity and work eligibility.

Have you previously been interviewed by us?

Yes No

Have you previously been employed by us?

Yes No

List any relatives working for us, department they work in, and relationship.

For reasons of supervision, safety, security, and morale, Solomons Nursing Center will not employ immediate family members for positions in working proximity with their immediate family member.

Have you ever been discharged or asked to resign?

Yes No

Select A File To Upload:

 

Agreement

 

If you agree to these terms and conditions, please type I agree in the field below.

 

Please click the checkbox below to verify your identity.