Employment Home / Employment Employment Application Jaffrey Rehabilitation and Nursing Center, LLC considers all applicants for all positions without regard to race, color, religion, sex, age, national origin, disability, marital status, sexual orientation or military status. To qualify for employment, you must satisfactorily complete employment interviews and tests as required and qualification must be supported by reference checks. Criminal background checks, drug testing and verification of licenses maybe conducted according to specific policies. If employment is offered, it may be contingent upon the outcome of a post-offer physical examination. After hire, you must provide required documentation that you are eligible to work in the United States and you must maintain all professional licenses, registrations and/or certificates as appropriate. Applicant Information Position Applied for Date available to start* Check the type(s) of position you will accept Full Time Part Time Per Diem Temporary Are you known by any other names? Yes No Shifts available to work 1st 2st 3st First Name* Last Name Middle Name Home Address* Apt.# Street* City* State* ZipCode Home Phone* Home Email* Cell Phone* Work Phone Have you previously applied here for employment? Yes No Have you previously been employed by Jaffrey Rehabilitation and Nursing? Yes No Do you have any relatives working here? Yes No If yes ,please provide name and relationship to you How did you hear about us? Advertisement Location Website Job Fair Relative or resident of a facility Referred by Other–Please describe Are you U.S. citizen or otherwise eligible to working the United States? Yes No Are you at least 18 years of age?* Yes No Are you willing and able to secure a New Hampshire Driver’s License if a license is required? Yes No If the position requires travel can you supply your own transportation? Yes No Have you ever been convicted of or pleaded no contest to a crime (felony or misdemeanor) that has not been officially annulled by a court? Yes No If yes, please explain; this does not automatically exclude you from consideration for employment. Have you ever been convicted of a criminal offense related to healthcare or have you ever been excluded, debarred or otherwise become ineligible for participation in any federal or state healthcare program such as Medicare or Medicaid? Yes No If yes, please explain Have you ever been discharged from any job? Yes No If yes, please explain Education and Skills Please list all schools: high school, vocational or technical school, business school, professional school and college education even if you did not graduate.School City State Did you graduate Degree Major School City State Did you graduate Degree Major School City State Did you graduate Degree Major School City State Did you graduate Degree Major If you have not received a High School Diploma have you completed a GED or a high School equivalent diploma? Yes No Please check off those computer skills or trade skills you are proficient atWord Processing Novice Skilled Plumbing Novice Skilled Spreadsheet Novice Skilled Electrical Novice Skilled Internet Use Novice Skilled Other Military Experience Have you ever served in any military or uniformed service organization? Yes No Branch From To Discharge Status Please describe any training relevant to the position being applied for Licensure/Certification Are you currently licensed/certified? Yes No License License Number Exp.Date (Please enter information if relevant to your license or certification plus all states you have been licensed in with appropriate license and corresponding number –attach separate sheet if necessary)Has your professional license ever been revoked, suspended, denied, restricted, limited or been made conditional or probationary in any way in this state or any other state? Yes No If yes, please explain. Have you ever voluntarily surrendered your professional license?? Yes No If yes, please explain. Do you have any investigation or action pending against any healthcare or professional license in the U.S. or any other country/territory? Yes No If yes, please explain. Have you ever been subject to an investigation or a disciplinary action by any healthcare licensing agency in this state or any other state or foreign country? Yes No If yes, please explain. Employment History-1 Employer Address Phone Number Position Dates: From Dates: To Supervisor Reason for leaving Duties Employment History-2 Employer Address Phone Number Position Dates: From Dates: To Supervisor Reason for leaving Duties Employment History-3 Employer Address Phone Number Position Dates: From Dates: To Supervisor Reason for leaving Duties Employment History-4 Employer Address Phone Number Position Dates: From Dates: To Supervisor Reason for leaving Duties What is your current salary? What is your salary expectation? May we contact previous employers for references? Yes No May we contact your current employer for reference? Yes No Please provide us with a list of 3 personal references we may contact, excluding family members, including mailing address, telephone number and email address if known.Name Years Known Address Occupation Telephone Number Email Name Years Known Address Occupation Telephone Number Email Name Years Known Address Occupation Telephone Number Email We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of his/her race, color, religion, sex, age, national origin, sexual orientation, disability, marital status or military status. The facts set forth above in my application and any resume provided for employment are true and complete to the best of my knowledge. I understand that any false answers, statements or implications and/or material omissions made by me in this application or other required documents shall be considered sufficient cause for denial of employment or termination. If I am hired, I understand my employment shall be terminable at will by either Jaffrey Rehabilitation or Nursing Center, LLCorme. I fully release Jaffrey Rehabilitation and Nursing Center, LLC from any liability resulting from the verification process. I understand that my employment is dependent upon completion of satisfactory references and criminal background checks and verification of license/certification, if applicable.Date Signature of Applicant NameThis field is for validation purposes and should be left unchanged.
