* = Required Information

To the applicant: We appreciate your interest in Groton Community Health Care Center. Please complete this form in as much detail as possible since a clear understanding of your background and work history will assist us in placing you in the position that best meets your qualifications and may help us in possible future upgrading.

All statements made by you on this application form will be carefully checked for accuracy. Remember to list all previous employment. We offer equal opportunities to all persons without regard to race, religion, age, national origin, citizenship, sex, military status, predisposing genetic characteristics, color, marital status, sexual orientation, disability, domestic violence victim status, or any other status protected by law. All information contained in this application will be held in strictest confidence. The use of this form does not indicate that positions are currently available and does not bind either party to any specific period of employment.

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Employee
Personal
Government Agency
Walk-In
Private Employment Agency
Other
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Can you work:
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Yes No
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Days Evenings Nights Rotation
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CAREER OBJECTIVES
Administration Geriatric Care MR/DD
SKILLS AND QUALIFICATIONS
Professional Licensure or Registry:


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EDUCATION
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High School


College


Nursing School


Other

MILITARY

*Discharge other than honorable are not absolute bar to employment.

PERSONAL
Yes No
Yes No
Yes No
Yes No

*Conviction will not necessarily result in disqualification for employment.

PERSONAL REFERENCES

Please list former associates and/or acquaintances who are familiar with your professional qualifications; we may contact these individuals for reference. Do not list relatives or previous employers.


EMPLOYMENT HISTORY

Please list your current and/or all previous employers. starting with the most recent. Explain any gaps in employment in comments section below. Use additional sheets if necessary. Complete and accurate information is required. Remember to list all previous employment.

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Dates Employed
Hourly Rate/Salary

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Dates Employed
Hourly Rate/Salary

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Dates Employed
Hourly Rate/Salary

Yes No
Dates Employed
Hourly Rate/Salary

Yes No
Dates Employed
Hourly Rate/Salary

If you are hired, a post-offer medical examination will be required before you start work. If the examination discloses medical conditions that prevent you from successfully performing the essential functions of the job, Groton Community Health Care Center will attempt to make accommodations to allow you to work. If no reasonable accommodations can be found, or they cause an undue hardship on Groton Community Health Care Center, the tentative offer of employment will be withdrawn.

It is the policy of Groton Community Health Care Center not to refuse employment to a qualified individual with a disability because of his/her need for an accommodation that would be required by the ADA.

APPLICANT'S AGREEMENT AND CERTIFICATION

"I certify that the information given by me in this application is true in all respects; and I agree that, if employed by Groton Community Health Care Center and any information is found to be false in any way, I may be subjected to dismissal without notice, if and when discovered."

"I agree, if employed, to work faithfully and diligently, to be careful and avoid accidents, to come to work promptly, and to maintain Resident/Consumer confidentiality."

"Should I accept an offer of employment, I agree to be employed for an introductory period and understand that I may be dismissed at anytime during this introductory period at the discretion of my employer. If employed, I agree to abide by all present and subsequently-issued center and personnel policies and rules."

"However, I also understand that after completion of the introductory period, my employment is for no set period of time and may be terminated by either party at any time."

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize Groton Community Health Care Center to request from former employers an evaluation of my job performance and dates of association and to contact my references and confirm all professional achievements stated within my application for employment. I release all persons involved from any and all claims of whatever nature I might have as a result of any and all responses given to Groton Community Health Care Center. Further, I understand all responses are the confidential property of Groton Community Health Care Center.

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