EMPLOYMENT APPLICATION Programs, services and employment are equally available to everyone. Please inform the Human Resources Department if you require reasonable accommodation for the application or interview. *Last Name: *First Name: Middle Initial: Address:   City:   State:   Zip   *Phone:   Cell/Other:   Email: Date available to start:  Social Security:  Salary Required: If you are under 18 and we require a work permit, can you furnish one?Yes  No Are you a citizen of the United States?Yes  No If not, are you legally allowed to work in the United States?Yes  No *Position applying for? Occupational Therapy Physical Therapy Speech Therapy RN/LPN Nursing Assistant Respite Care House Keeping    *Type of employment desired? Full Time Part Time Temporary Seasonal Have you ever pleaded "guilty" "no contest", or being convicted of a crime?Yes  No If yes, give date and details: Answering "yes" to these questions does not constitute an automatic rejection for employment. Date of these offense, seriousness and nature of the violation, rehabilitation and position applied for will be considered. Driver's license number if applicable to position:  State: SUMMARIZE YOUR SPECIAL SKILLS OR QUALIFICATIONS: How were you referred to us? Dates of Employment : From //  To: //   Position(s) Held: Firm:   Address: Phone:   Supervisor:  Title Responsibilities: Starting Salary & Title:   Ending Salary & Tilte: Reason for Leaving: May we contact this employer for a reference?Yes  No Dates of Employment : From //  To: //   Position(s) Held: Firm:   Address: Phone:   Supervisor:  Title Responsibilities: Starting Salary & Title:   Ending Salary & Tilte: Reason for Leaving: May we contact this employer for a reference?Yes  No Dates of Employment : From //  To: //   Position(s) Held: Firm:   Address: Phone:   Supervisor:  Title Responsibilities: Starting Salary & Title:   Ending Salary & Tilte: Reason for Leaving: May we contact this employer for a reference?Yes  No