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INFO REQUEST FORM
The Homestead Employment Application
An Equal Opportunity Employer
*
Indicates required field
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Phone Number
*
Desired Wage
*
Position Applying For (choose one)
*
Nurse
STNA
Dietary
Laundry
Maintenance
Activities
Marketing
Social Services
Hospitality Aide
Type of Work
*
Full-Time
Part-Time
Temporary
Permanent
Date Available to Begin Work
*
Are you on lay-off and subject to recall?*
*
Yes
No
Have you filed an application here before?*
*
Yes
No
If yes, please give date:
*
Referral Source:
*
Advertisement
Friend
Relative
Walk-in
Employment Agency
Other
Employment Experience
Please start with your present or last job. Include military service assignments and volunteer activities.
Exclude organization names which indicate race, color, religion, sex or national origin.
Employer Name
*
Dates Employed
*
Employer Address
*
Line 1
Line 2
City
State
Zip Code
Country
Job Title
*
Job Duties
*
Supervisor and Title
*
Phone Number
*
Reason(s) for Leaving
*
May we contact your employer for a reference?
*
Yes
No
Employer Name
*
Dates Employed
*
Employer Address
*
Line 1
Line 2
City
State
Zip Code
Country
Job Title
*
Job Duties
*
Supervisor and Title
*
Phone Number
*
Reason(s) for Leaving
*
May we contact your employer for a reference?
*
Yes
No
Employer Name
*
Dates Employed
*
Employer Address
*
Line 1
Line 2
City
State
Zip Code
Country
Job Title
*
Job Duties
*
Supervisor and Title
*
Phone Number
*
Reason(s) for Leaving
*
May we contact your employer for a reference?
*
Yes
No
Education
High School
*
Completed?
*
Yes
No
Did you receive a
*
Diploma
GED
College/University
*
Number of Years Completed
*
Course of Study
*
College Degree Earned?
*
Yes
No
If yes, please list
*
Military Service
Branch
*
Years in Service
*
Rank at Discharge
*
Type of Discharge
*
If other than honorable, please explain:
*
State any additional information you believe may be helpful in considering your application
*
References
Please list the names, addresses and phone numbers of three individuals, other than relatives, that may be contacted for a reference. Two of these individuals should be work related.
Reference #1
*
Reference #2
*
Reference #3
*
Emergency Information
Please list the name, address and phone number of an individual to be contacted in the case of an emergency
Emergency Contact
*
Applicant's Statement
Application will not be accepted if this oath is omitted.
I solemnly swear or affirm that the answers I have made to each and all of the questions are complete and true to the best of my knowledge and belief. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I hereby waive all provisions of law forbidding my physician or other person who has attended or examined me, or who may hereafter attend or examine me, colleges or universities which I attended, or past employers from disclosing any knowledge or information which they thereby acquired relevant to my employment and I hereby consent that they may disclose such knowledge or information to Logan Acres. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract for employment.
Electronic Signature of Applicant
*
First
Last
Date
*
Submit
HOME
ABOUT US
OUR LEGACY
OUR MISSION
RESOURCES
SERVICES
THERAPY
LONG TERM CARE
APARTMENT LIVING WITH ASSISTANCE
EMPLOYMENT
CONTACT US
INFO REQUEST FORM
