Employment

This employment application takes approximately 30 minutes to complete. Please be sure to have on hand: Driver’s license, previous employer and reference information.

Application for Employment

General Information

Position you are applying for: * Certified Medicine AideCharge Nurse (RN or LPN)Geriatric Nursing Assistant

Last Name:

First Name

Middle Name

Street Address

City

State Please Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Email Address

Social Security Last 4 Numbers

(xxx xx ----)

Home Phone (include area code)

Work Phone (include area code)

Cell Phone (include area code)

Date available for work

Lowest pay you will accept

Will you accept full-time employment?

Yes

No

Will you accept part-time employment?

Yes

No

Do you want to attach a RESUME?

Drop a file here or click to upload Choose File

Maximum file size: 516MB

You may do so here. Unfortunately, we cannot accept files over 4MB.

Driver's License

Do you have a valid Driver's License

Yes

No

Driver's License Number

Expiration Date

Driver's License State Please Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Type of License

Non-commercial

Commercial

Class

List all other professional licenses, registrations and certificates:

Type

Number

Expiration Date

Type

Number

Expiration Date

Type

Number

Expiration Date

List all machines or equipment, including office equipment, that you can operate skillfully

Typing speed

WPM

Additional qualifications and skills

Education and Training

Select highest grade completed 910111213141516Graduate

High School

Name

City

State Please Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Did you graduate?

Yes

No

G.E.D. or equivalent?

Yes

No

College

Name

City

State Please Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Did you graduate?

Yes

No

Degree(s)

Major

Minor

Hours completed

List additional training, educational seminars, or short courses completed

References

Name

Phone

Address

Relationship

Name

Phone

Address

Relationship

Name

Phone

Address

Relationship

Experience

Starting with your current or most recent job, list all positions you have held in the last ten years. If you consider it appropriate to this application, you may include as an addendum, positions held earlier than ten years ago

Drop a file here or click to upload Choose File

Maximum file size: 516MB

Be concise, but do not omit information which may be relevant to the position for which you are applying. Please explain any lapses in employment. You may attach a .txt or .doc (Word document) here.

Current or Most Recent Job

Start Date of Employment

End Date of Employment

Job Title *

Number of Persons Supervised

Salary *

Hours Per Week *

Name of Supervisor *

Employer's Phone (include area code) *

Name and Address of Business or Employer *

Reason for Leaving *

May We Contact This Employer? *

Yes

No

If No, Why?

Description of Duties *

Prior Job 2 - Click to expand

Start Date of Employment

End Date of Employment

Job Title

Number of Persons Supervised

Salary

Hours Per Week

Name of Supervisor

Employer's Phone (include area code)

Name and Address of Business or Employer

Reason for Leaving

May We Contact This Employer?

Yes

No

If No, Why?

Description of Duties

Prior Job 3 - Click to expand

Start Date of Employment

End Date of Employment

Job Title

Number of Persons Supervised

Salary

Hours Per Week

Name of Supervisor

Employer's Phone (include area code)

Name and Address of Business or Employer

Reason for Leaving

May We Contact This Employer?

Yes

No

If No, Why?

Description of Duties

Prior Job 4 - Click to expand

Start Date of Employment

End Date of Employment

Job Title

Number of Persons Supervised

Salary

Hours Per Week

Name of Supervisor

Employer's Phone (include area code)

Name and Address of Business or Employer

Reason for Leaving

May We Contact This Employer?

Yes

No

If No, Why?

Description of Duties

Prior Job 5 - Click to expand

Start Date of Employment

End Date of Employment

Job Title

Number of Persons Supervised

Salary

Hours Per Week

Name of Supervisor

Employer's Phone (include area code)

Name and Address of Business or Employer

Reason for Leaving

May We Contact This Employer?

Yes

No

If No, Why?

Description of Duties

Prior Job 6 - Click to expand

Start Date of Employment

End Date of Employment

Job Title

Number of Persons Supervised

Salary

Hours Per Week

Name of Supervisor

Employer's Phone (include area code)

Name and Address of Business or Employer

Reason for Leaving

May We Contact This Employer?

Yes

No

If No, Why?

Description of Duties

Additional Information

Are you related by blood or marriage to any Nursing Center Employee(s)?

Yes

No

St. Mary's Nursing Center, Inc. does not prohibit the hiring of relatives. However, it is against our Nepotism policy for an employee to be under the direct supervision of a relative.

How did you hear about St. Mary's Nursing Center, Inc?

How did you hear about the position you are applying for?

Friend

Advertisement

OtherOther

Did a current member of our staff refer you to our facility?

Yes

No

Who?

Have you ever been employed by St. Mary's Nursing Center, Inc.?

Yes

No

Start Date of Employment

End Date of Employment

Postion Held

Reason for Leaving

Are you legally authorized to accept work and remain in the United States? (Proof of identity and authorization will be required upon employment)

Yes

No

Are you currently 18 years of age or older?

Yes

No

If not, state your age

Can you provide a work permit?

Yes

No

Authorization for Release of Information

Click Here to Read the SMNC Hiring Terms

Terms and Conditions *

It is okay to investigate me. All of the information I provided is true.

Terms and Conditions *

I have read and agree to the SMNC hiring terms.

St. Mary’s Nursing Center, Inc. is an equal opportunity employer and does not discriminate against any employee or applicant for employment due to age, sex, marital status, pregnancy, national origin, religion or beliefs, race, color, political affiliation or opinion, handicap, disability, or any other legally protected or non-merit factor.