Employment Application

First Name *

Last Name *

Position You Are Applying For *

Seeking *

Full-time

*Part-Time

Summer

Per Diem

Shift Preference *

Day

Evening

Night

Weekend Availability *

Yes

Address *

City *

State *

Zip *

Phone Number *

Alternate Phone

Email *

Have you previously been employed by Saunders House? *

Yes

If yes, please list the dates

List any relatives who are currently employed by our facility

Name

Relationship

Department

Name

Relationship

Department

Are you legally eligible for employment in the United States? *

Yes

What prompted you to apply for employment at Saunders House?

Employee Referral

Other

Education

High School Name *

High School City *

Did you graduate? *

Yes

College/Trade School Name

College/Trade School City

Did you graduate?

Yes

Degree or Major

Other Name

Other City

Did you graduate?

Yes

Other Degree or Major

Professional Licensure / Registration / Certification

Type of License, Registry or Certification

Issuing State or Organization

Number

Expiration Date

Month

Day

Year

IV Certification Expiration Date

Month

Day

Year

CPR Certification Expiration Date

Month

Day

Year

Geriatric Certification Expiration Date

Month

Day

Year

Previous Employment (Starting with most recent employment)

Employer *

Start Date *

Month

Day

Year

End Date *

Month

Day

Year

Address *

City *

State *

Zip *

Salary * $

Position Title *

Reason For Leaving *

Supervisor's Name *

Supervisor's Phone *

Brief Description of Duties *

Previous Employment

Employer

Start Date

Month

Day

Year

End Date

Month

Day

Year

Address

City

State

Zip

Salary $

Position Title

Reason For Leaving

Supervisor's Name

Supervisor's Phone

Brief Description of Duties

Additional Information

Please list any additional information that you think would be applicable (internships, memberships in organizations, additional relevant skills and employment, etc.)

Upload Your Resume (.doc, .docx, .odf, .pdf) *

Files must be less than 2 MB.
Allowed file types: odf pdf doc docx.

Agreement *

I certify that my answers to the foregoing questions are true and correct to the best of my knowledge and belief. Saunders House is hereby authorized to investigate fully all information contained herein. I agree that any misrepresentation of facts contained in this application may be cause for my dismissal.