Application For Employment

Personal Information
First Name:
Last Name:
Date of Application:
Address:
City:
County:
State:
Zip Code:
Home Phone:
Alt Phone:
Employment
Desired Position(s):
Desired Status:
Full time (32hrs + per week)
Part time
Contingent
Desired Shift:
7-3
3-11
11-7
7AM-7PM
7PM-7AM
Other:
Date you can start:
Rate of pay desired:
Can you work every other weekend?
Yes
No
How were you refered to Columbus West Park?
Can you, upon employment provide lawful documentation establishing your identity and eligibility to be legally employed in the United States? Yes
No
Are you under 18 years of age? Yes
No
If you are under 18 years of age, do you have a work permit? Yes
No
Are any of your relatives presently employed with this company?
If so, who? 		Yes
No
Have you been convicted of any crime in the past 7 years?

If yes, please describe fully the criminal conviction(s), listing the nature of the offense, your age at the time of the offense, and your rehabilitation since the convictions. A conviction will not necessarily bar your employment with Columbus West Park, but nursing home regulations do require us to perform a criminal background check at the time of orientation, and set guidelines for employment eligibility.

 Yes
No
Personal References
  Reference 1 Reference 2
Name:
Phone:
Address:
Educational Background
  High School College 1
Name:
City/State:
Major/Minor:
Years Completed
or Diploma:
Graduated:
 Yes No Yes No
GPA:
     
  College 2 Technical/Business School
Name:
City/State:
Major/Minor:
Years Completed
or Diploma:
Graduated:
 Yes No Yes No
GPA:
     
  Graduate School  
Name:
  
City/State:
  
Major/Minor:
  
Years Completed
or Diploma:
 
Graduated:
 Yes No  
GPA:
  
License/Certification Number:
List any job related training (i.e. nurse aide certification, activities certification, etc.), seminars, vocational or skilled training you have received that was not covered above:
List any job related equipment that you have been trained to use, including computer software, if applicable:
Employment History
Have you ever been employed at Columbus West Park? Yes No
If so, please explain your reason for leaving:
Complete the following for the last four places of employment, starting with the most recent.
  1. 2.
Company Name:
Phone Number:
Starting Date:
Ending Date:
Supervisor's Name:
Your Job Title:
Starting Salary:
Ending Salary:
Describe Duties:
Reason for Leaving:
     
  3. 4.
Company Name:
Phone Number:
Starting Date:
Ending Date:
Supervisor's Name:
Your Job Title:
Starting Salary:
Ending Salary:
Describe Duties:
Reason for Leaving:
May we contact your present employer at this time? Yes No
Are you currently on “lay-off” status and subject to recall? Yes No
Other information you wish to provide regarding past employment experience:
Give the reasons for jobs from which you were fired:

Notice to Applicants:

Columbus West Park places a high emphasis on safety, both for our employees, and to protect our residents. To maintain those high standards, we are a Substance Free Workplace. Any offer of employment is conditional, based on the outcomes of reference/license checks during the pre-hire process, and drug testing and a criminal background check during the probationary period.

Applicants Statement

I certify that the information contained in this application is true and complete to the best of my knowledge. I understand that if employed, false statements or omissions on this application are grounds for immediate dismissal upon delivery thereof. I authorize the references listed above to give you any and all information concerning my previous employment, and any pertinent information they may have personal or otherwise, and release all parties from liabilities for any damage that may result from furnishing the same to you. If employed by the Company, as an “Employee at Will” under Ohio Law, I agree to abide by the Company’s Employee Handbook, rules and regulations. I also agree not to commence any action or suit relating to my employment by Columbus West Park Nursing and Rehabilitation Center more than six months after the date of termination of such employment, and to waive any statute of limitations to the contrary.