Employment Application Step 1 of 6 16% General InformationName: * Required First Middle Last Current Address: * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone: * Required Business Phone: Cell Phone: Email: * Required Position Applying For: * Required Are you seeking: * Required Full Time Part Time PRN Shift Availability: * Required Day Evening Night Salary/Wage Expected: * Required Date Available: MM slash DD slash YYYY How were you referred to us? Are you 18 years of age or older? * Required Yes No Are you currently employed? * Required Yes No If so, may we contact your current employer? Yes No In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.Are you legally able to work for any employer in the United States under the immigration laws of the United States? * Required Yes No Have you even been convicted of or plead guilty to a felony? * Required Yes No (A conviction record will not necessarily disqualify you from employment.)If yes, please provide details: * Required Have you ever been found guilty by a court of law of abusing, neglecting, mistreating, or misappropriating the property of an individual in a healthcare setting? * Required Yes No (A conviction record will not necessarily disqualify you from employment.)If yes, please provide details: * Required Are you or have you ever been excluded from participation in the federal health care programs (for example, Medicare and Medicaid)? * Required Yes No (A conviction record will not necessarily disqualify you from employment.)If yes, please provide details: * Required Have you ever been employed with Flannery Oaks Guest House? * Required Yes No If yes, when? MM slash DD slash YYYY Do you have any relatives employed at Flannery Oaks Guest House? * Required Yes No Company policy restricts close relatives working in a reporting relationship.If yes, please give their names: * Required Registry, certification, or professional license 1: NUMBER Registry, certification, or professional license 1: STATE Registry, certification, or professional license 2: NUMBER Registry, certification, or professional license 2: STATE Registry, certification, or professional license 3: NUMBER Registry, certification, or professional license 3: STATE Have you ever had your professional license or certification suspended, revoked, or restricted? * Required Yes No If yes, please provide details: EducationHigh School Name: * Required City/State: * Required City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Graduated? * Required Yes No Last Year Completed: * Required 1 2 3 4 Type of Degree: College/University Name: City/State: City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Graduated? Yes No Last Year Completed: 1 2 3 4 Type of Degree: Post Graduate Name: City/State: City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Graduated? Yes No Last Year Completed: 1 2 3 4 Type of Degree: Technical/Business Name: City/State: City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Graduated? Yes No Last Year Completed: 1 2 3 4 Type of Degree: Work History List the three most recent employers. Begin with most recent employer. Company #1 Name: * Required Phone: * Required Job Title: * Required Supervisor's Name: * Required Address: * Required Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Start Date: * Required MM slash DD slash YYYY End Date: * Required MM slash DD slash YYYY Salary/Wage: Describe your duties: * RequiredReason for Leaving: * RequiredEligible for rehire? * Required Yes No Company #2 Name: Phone: Job Title: Supervisor's Name: Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Start Date: MM slash DD slash YYYY End Date: MM slash DD slash YYYY Salary/Wage: Describe your duties:Reason for Leaving:Eligible for rehire? Yes No Company #3 Name: Phone: Job Title: Supervisor's Name: Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Start Date: MM slash DD slash YYYY End Date: MM slash DD slash YYYY Salary/Wage: Describe your duties:Reason for Leaving:Eligible for rehire? Yes No Skills and AffiliationsDescribe any previous work history or particular job responsibilities listed in your Employment History that you believe are important or should be considered. Include any additional information about your qualifications or experience you feel may be relevant to the job for which you are applying.List any professional affiliations or accreditations that have a direct bearing upon your qualifications for the job for which you are applying. Professional References Please list three personal references, other than family members.Reference 1 - Name: * Required First Last Phone: * Required Address: * Required City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Reference 2 - Name: * Required First Last Phone: * Required Address: * Required City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Reference 3 - Name: * Required First Last Phone: * Required Address: * Required City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Applicant Must Read and Sign Below:I certify that the answers I gave in this application and in any interviews are true and complete to the best of my knowledge. I authorize investigation of all statements in this application and authorize my former employers, government agencies, schools, and personal references to provide any information they have regarding me. I release all employers, government agencies, schools, and personal references from any liability for providing information concerning me. If the results of this investigation do not meet the required standards for employment, I understand that an offer of employment may not be extended, may be revoked, or that my employment may be terminated. I understand that this application is not a contract of employment. I understand that if I give false or misleading information on my application or in any part of the employment process, I may be fired. I agree to follow the Company’s rules and regulations. I understand that employment is at-will, meaning that either I or the company may terminate the employment relationship at any time for any reason not expressly prohibited by law. No one except a managing member of the company is authorized to change this at-will status, and any change must be done in writing and signed. I understand that the Company may provide other future employers with reference information concerning my performance during employment and the reason for ending my employment. I consent to the release of this information. I agree to inform the company if I obtain any other employment while working for the company, if I am hired here. I acknowledge that I have read and understand these statements.Electronic Signature: * Required First Last Δ
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