Application for Employment

Applicants for employment with Gillette Skilled Nursing and Rehabilitation are evaluated and selected on the basis of individual merit and ability with respect to the position being filled. Applicants are selected and hired without discrimination based on race, color, religion, sex, age, national origin, political affiliation, disability or ancestry. Fingerprinting and a criminal background check will be conducted on all applicants under final consideration for a position with Gillette SKilled Nursing and Rehabilitation. Applicants may request reasonable accommodation in the application/interview process. 

Personal Data
Name
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Maiden Name
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Address
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Phone --
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E-mail
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Position Desired
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Date Available to Start //
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When are you available to work?
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If part-time, please specify days and times.
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Briefly specify any special skills or qualifications you have which you feel are related to the position for which you are applying.
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Have you ever been convicted of a crime (felony or misdemeanor) other than a minor traffic violation?
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If yes, please explain.
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Work History
Have you ever previously applied for a job at this facility?
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If yes, when?  
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Have you ever been employed by this facility?
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If yes, when?  
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List any friends or relatives you have working for us. Please specify your relationship.
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Have you ever been dismissed from or asked to resign from any employment position?
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If yes, please explain.
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Employment History
List your two most recent places of employment in chronological order - last position first. Include the U. S. Military. If a required field does not apply to you, please type N/A.
Current/Most Recent Employer
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Supervisor
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Phone --
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Position Held
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Final/Current Salary
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Dates Employed  
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Dates Employed  
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Reason for Leaving
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Second Most Recent Employer
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Supervisor
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Phone --
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Position Held
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Final Salary
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Dates Employed  
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Dates Employed  
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Reason for Leaving
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Have you ever been bonded?
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If yes, on which jobs?
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Educational Data
High School
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Did you graduate from high school?
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College/University
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Did you graduate?
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Major/Degree
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Other Schools Attended and Professional Licenses/Certifications
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Attach Resume
Resume
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 Please attach your resume here
Certification
This institution does not discriminate in hiring or in any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination. I voluntarily give the institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons,companies or corporations supplying such information. I consent to take the physical examinationand such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physician examination which relates to the essential duties I would be required to perform. I understand that my employment is at will and that either party is free to determine the employment relationships at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. If employed, I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory evidence of identity and eligibility for employment.
Applicant's Signature
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Today's Date //
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