Employment Application

EMPLOYMENT DESIRED
Position You Are Applying For*
Shift(s) You Can Work
- Days
- Evenings
- Nights
- Any
- On Call
Date you can start*
I am applying for:
- Full Time
- Part Time
EDUCATION
Highest level of education you have completed? Include RN, LVN, CNA, or other trade school.
Please write "no" if not applicable.
Name of last school attended? Include RN, LVN, CNA, or other trade school.
Please write "no" if not applicable.
Degree or certification attained?
Please write "no" if not applicable.
Vocational or trade training?
Please write "no" if not applicable.
Do you have friends or relatives working for Community Care on Palm? If so, list them here or state "none".

WORK EXPERIENCE
List below your work experience, starting with your present or last place of employment.
EMPLOYMENT #1
Name of Company
Dates of Employment
Start Date
End date
End Date
Work Performed
Street Address
City
State
Zip
Phone
Supervisor's Name
Position Held
Reason for Leaving
EMPLOYMENT #2
Name of Company
Dates of Employment
Start Date
End Date
End Date
Work Performed
Street Address
City
State
Zip
Phone
Supervisor's Name
Position Held
Reason for Leaving
EMPLOYMENT #3
Name of Company
Dates of Employment
Start Date
End Date
End Date
Work Performed
Street Address
City
State
Zip
Phone
Supervisor's Name
Position Held
Reason for Leaving
Please explain any gaps in your employment, other than those due to personal illness, injury or disability*
Have you ever been fired or asked to resign from a job? If yes, please explain
If you have never been fired, please state "no".
Certification Statement
I certify that all the information submitted by me on this application is true and complete, and I understand that if any false or misleading information, omissions, or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations, and I understand that these rules and/or the employee handbook do not form a contract of employment either expressed or implied, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed with or without cause and with or without notice, at any time by the company. I understand that no company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.
Resume
Accepted file types: pdf, doc, docx.
Please attach your resume here.
I understand that Community Care on Palm conducts a job-related background check. A comprehensive background check may consist of prior employment verification, professional reference checks, education confirmation, and/or criminal record and credit checks. Third-party services may be hired to perform these checks.
Electronic Signature
To prevent spam please enter: "1234"*

PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION

WORK EXPERIENCE

EMPLOYMENT #1

EMPLOYMENT #2

EMPLOYMENT #3

Certification Statement