Avanti Health Employment Application

Which Location are you applying to?

Sky View Nursing Center Villa Maria Health & Rehabilitation Center Villa Marina Health & Rehabilitation Center Beacon Ambulance

Would you like to attend the FREE CNA Class provided?

Yes No

If you cannot be reached at above phone number, where may we contact you?

Phone *

Name of Person *

How did you learn of this opening?

Will you accept employment of:

Full time Part time Temporary

Date Available

If under 18 years of age, will you be able to provide a work permit?

Yes No

Did you graduate?

Yes No

If yes, date

Diploma, Degree, or Certificate Received

Did you graduate?

Yes No

If yes, date

Diploma, Degree, or Certificate Received

Did you graduate?

Yes No

If yes, date

Diploma, Degree, or Certificate Received

Other Classes/Training

Extracurricular Activities While in School

Areas of Specialization or Major Interest

Professional Organization Membership, Honors Received, Volunteer or Community Service or Other Qualifications

Military Branch

Entry Rank

Separation Rank

Separation Date(s)

Military Occupational Speciality

Specialized Training

List Service Awards, Commendations

List current (or most recent) employer first and all others in reverse chronological order.

Company

Address

Employed From (Month/Year)

Employed To (Month/Year)

Starting Salary

Ending Salary

Position Title

Job Description & Responsibilities

Immediate Supervisor's Name & Title

Phone

May we contact for reference?

Yes No

Company

Address

Employed From (Month/Year)

Employed To (Month/Year)

Starting Salary

Ending Salary

Position Title

Job Description & Responsibilities

Immediate Supervisor's Name & Title

Phone

May we contact for reference?

Yes No

Company

Address

Employed From (Month/Year)

Employed To (Month/Year)

Starting Salary

Ending Salary

Position Title

Job Description & Responsibilities

Immediate Supervisor's Name & Title

Phone

May we contact for reference?

Yes No

Company

Address

Employed From (Month/Year)

Employed To (Month/Year)

Starting Salary

Ending Salary

Position Title

Job Description & Responsibilities

Immediate Supervisor's Name & Title

Phone

May we contact for reference?

Yes No

Company

Address

Employed From (Month/Year)

Employed To (Month/Year)

Starting Salary

Ending Salary

Position Title

Job Description & Responsibilities

Immediate Supervisor's Name & Title

Phone

May we contact for reference?

Yes No

Have you ever been convicted of a crime?

Yes No

If so, for what, when and where?

Conviction of a criminal offense will not necessarily preclude your employment.

Use this space to give us further information which may assist us in placing you.

Primary Position Desired

Will you accept another position?

Yes No

If yes, what?

Are you available to work weekends?

Yes No

Are you available to work holidays?

Yes No

Are you available to work rotating shifts?

Yes No

Are you available to work on call?

Yes No

I understand that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as directed by my department head or administrator of this institution.

If your availability status changes, it is your responsibility to notify your department head or the administrator. Such changes will be effective then, for any future employment.

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential duties I would be required to perform.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory evidence of identity and eligibility for employment.