Name Full Address Email Address

Phone# Alternate # Desired Work Location

Spring Creek is a 24-7 facility; available shifts may vary.
Full-Time Employment Part-Time Employment Desired Position

Education (Starting with High School)

School Address Years Attended

Graduate: Yes No Degree/ Diploma

School Address Years Attended

Graduate: Yes No Degree/ Diploma

School Address Years Attended

Graduate: Yes No Degree/ Diploma

Current Licensure and Certification (Please mark all that are applicable)

CPR: First Aid: Food Handlers MedCertified: CNA: MA: EMT: LPN: RN: RT:

Special qualifications or skills related to working with elderly:

Employment History

Employer's Name Address Phone#

Dates of Employment Title Able to Contact: Yes No

Supervisor's Name Reason for Leaving

Employer's Name Address Phone#

Dates of Employment Title Able to Contact: Yes No

Supervisor's Name Reason for Leaving

Employer's Name Address Phone#

Dates of Employment Title Able to Contact: Yes No

Supervisor's Name Reason for Leaving

Professional References

Name Phone# Relationship

Name Phone# Relationship

Name Phone# Relationship

Qualifying Questions

Do you have any physical limitation or health conditions that may affect your ablility to work in the position you are applying for?

Yes: No: If Yes, Please Explain

Are you willing to submit to a physical examination by a designated physician to verify your current health condition is suitable to perform the work required? Yes: No:

Have you ever been charged or convicted of a felony or had any military convictions or charges? Yes: No:

State law prohibits us from employing sex offenders. Are you a registered sex offender? Yes: No:

Spring Creek is a smoke free organization. Smoking is prohibited on faciliy grounds or during working hours.

 

The applicant certifies that all answers and statements on this application are true and complete to the best of the applicants knowledge. The applicant understands that should an investigation disclose untruthful or misleading answers or if the applicant fails to pass a required pre-employment drug test or background check, the application may be rejected, removed form consideration, or employment terminated.



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