Employment Applications

Employment Application Fillable PDF Download Fillable PDF

Good Samaritans Living Center
Employment Application

We do not discriminate in hiring or employment on the basis of race, color, religious creed, national origin, sex, age or handicap. This application will be given every consideration; however its receipt does not imply that the applicant will be employed.

A. Personal Information

Birth Date *

First Name *
Middle Name
Last Name *

Phone Number *
Email Address *

Present Address – Street *
City *
State *
ZIP *

Permanent Address – Street
City
State
ZIP

List any friends or relatives working for us

Have you worked for us before? *
If yes, when?

Convicted of or pled guilty to a criminal felony? *
If yes, explain

B. Employment Desired

Position(s) Applied For *
Salary Requirements

Date Available *
Hours Desired *
Days / Hours Available

How did you learn of this opening?
Currently Employed? *

May we contact your present employer?

Why are you interested in this position and how are you qualified? *

C. Education

Grammar School – Name & Location
Years Attended

High School – Name & Location
Years Attended

College – Name & Location
Years Attended

Major
Degree Received

Trade / Business / Correspondence School
Training Courses

Nursing Applicants Only

License / Registration Number
Date Issued
State
Expires

D. Work History — Last 4 Employers (Most Recent First)

Dates (From/To)	Name & Address of Employer	Salary	Position	Reason for Leaving

Total Number of Jobs Held in Last 10 Years

E. References

Three persons not related to you, known at least one year.

Name	Address	Business	Phone

The applicant understands that neither this document, nor any offer of employment from the employer constitutes an employment contract unless a specific document to that effect is executed by the Chief Executive Officer of Employer and the Employee.

I hereby declare that my answers to the foregoing questions are full, complete and true. I authorize any physician, practitioner or hospital to furnish employer any information regarding my health. I authorize employer to investigate and verify all statements contained in this application. I release employer from any liability as a result of any such inquiries or disclosures.

Signature (type full name) *
Date *