Employment Application

Your information will be used for preliminary screening purposes. Should you be contacted for an interview, you will be required to complete an application for employment.

Position Desired *
Salary Requirement *
Date Available * / MM / DD YYYY
Availability * Full-Time Part-Time Casual/Per Diem Temporary Shift Rotation (Day/Eve, Eve/Night, or Night/Day Days Eves Nights Weekdays
Contact and Personal Information
Name * First Last
Email *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone * - (###) - ### ####
Alternate Phone * - (###) - ### ####
Were you known under any other name in previous positions listed on this application? * yes no
If so, what name?
Are you legally authorized to work in the United States? * yes no
Are you 18 years of age or older? * yes no
If not, state age
Do you have a valid work permit? * yes no
Have you ever plead "guilty" or "no contest" to a felony or a crime? * yes no
Have you ever been "convicted" of a felony or a crime? * yes no
Date / MM / DD YYYY
Details
Date / MM / DD YYYY
Details
Date / MM / DD YYYY
Details
Have you ever worked at The Highlands Living Center * yes no
If so, when?
Why did you leave?
Do you have any relatives who work at The Highlands Living Center? * yes no
If yes, please list names and departments
How did you hear about this position? * Ad Internet Employee Other
If Employee, name please
Other
License
Are you a certified or registered professional? * yes no
Which state(s)?
Date of certification, registration, or application / MM / DD YYYY
Certificate/Registration
Application #
Education
Please indicate your highest level of education: *
Work History
Position Title *
From * / MM / DD YYYY
To * / MM / DD YYYY
Employer Name *
Supervisor * First Last
Employer Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Job Duties *
Starting Pay Rate * . Dollars Cents
Ending Pay Rate * . Dollars Cents
Reason for Leaving *
Position Title *
From * / MM / DD YYYY
To * / MM / DD YYYY
Employer Name *
Supervisor * First Last
Employer Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Employer Phone# * - (###) - ### ####
Job Duties *
Starting Pay Rate * . Dollars Cents
Ending Pay Rate * . Dollars Cents
Reason for Leaving *
Position Title *
From * / MM / DD YYYY
To * / MM / DD YYYY
Employer Name *
Supervisor * First Last
Employer Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Employer Phone# * - (###) - ### ####
Job Duties *
Starting Pay Rate * . Dollars Cents
Ending Pay Rate * . Dollars Cents
Reason for Leaving *
May we check references with your present and form employer? * yes no
If no, why not?

Employment Application

Employment Application

Contact and Personal Information

License

Education

Work History