Employment Application Please fill out the Employment application and then schedule an in-person interview. Thank you for your interest in our facility. 12345 PERSONAL DATA Lutheran Home of Southbury is an equal opportunity employer. This Center provides equal employment opportunities to all qualified employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.Date Last* First* Middle Social Security Number This form is not a secured online form if you wish to withhold this information for now, please just enter your last 4 and provide us with the entire number during your interview. Thank you!Address*Home Phone* Email address* How were you referred to us? Newspaper School Walk In Employee Agency Other Name of Referral Source: Are you legally authorized to work in the United States? Yes No Note: If you are hired, you will be required to submit proof of legal right to work in the United States.Are you over 18 years of age? Yes No If no, are you over 16 years of age? Yes No Professional License Held License Number PERSONAL AVAILABILITYIndicate the position for which you are applying: Number of hours per week you are interested in? Shift Desired Days Evenings Salary Desired When could you start? Have you ever worked for this company before? Yes No If yes, please specify date, facility/division and location: Have you ever applied for employment with this company before? Yes No Nursing facilities are open 24-hours per day, 365 days per year. Therefore, would you be willing to work nights? Nights? Rotating Work Schedule? Flexible Schedule? Overtime? Please check the shifts you are willing to work.Comments:EMPLOYMENT HISTORY List below the names of all employers ( you may list volunteer positions as well as paid positions, if you wish). List present employer or most recent employer first. EMPLOYER #1Employer AddressDates of Employment Reason for leaving Title/Nature of work: Name/Title of Immediate Supervisor: Phone EMPLOYER#2Employer AddressDates of Employment Reason for LeavingTitle/Nature of work: Name/Title of Immediate Supervisor Phone EMPLOYER #3Employer AddressDates of employment: MM slash DD slash YYYY Reason for leaving? Title/Nature of work: Name/Title of Supervisor Phone Are you employed now? Yes No If yes, may we inquire of your present employer? Do you have any commitments to another employer which might affect your employment with us?4. Are you subject to any restrictive covenants from your prior employment such as agreements to protect confidential or propriety information or agreements not to compete? If so, please explain. REFERENCES Provide the following information regarding 3 persons not related to you who have known you longer that 1 year (preferably work related.) REFERENCE #1Name AddressPhoneBusiness Years acquainted? Reference checked by? REFERENCE #2Name AddressPhoneBusiness Years acquainted? Reference checked by? REFERENCE #3Name AddressPhoneBusiness Years acquainted? Reference checked by? EDUCATIONAL DATAName and type of school: AddressPhoneMajor or course studied Graduated (Y or N) Degree Name and type of school? AddressMajor or course studied Graduated (Y or N) Degree Name and type of school? AddressMajor or course studied Graduated (Y or N) Degree MISCELLANEOUSWere you in the U.S. Armed Forces? Yes No If yes, what Branch? Dates of Duty? From: ______ To: ______ format please.Rank at Separation? Briefly describe your duties: Note: Lutheran Home of Southbury does not discriminate on the basis of National Guard or Reserve Unit Duty Obligations2. Please list any other information you think would be helpful to us in considering your for employment, such as organizations, activities, accomplishments, computer skills, etc. Exclude all information indicative of age, sex, sexual orientation, race, religion, color, national origin, disability, or handicap.AGREEMENT(Please read the following statements carefully). I understand and agree that prior to any job offer, I will be given a written description of that job and will be asked about my ability to perform specific job functions or duties involved in that job. I certify that all information on this application and any other material provided by me are true and complete. I agree that falsified information, misrepresentation, or omissions in this application, or any accompanying resume or other materials will disqualify me from consideration for employment with the Lutheran Home of Southbury and will be considered justification for dismissal whenever discovered. Unless otherwise noted, I authorize The Lutheran Home of Southbury or its agents to investigate and/or verify all information in this application, including contacting persons, schools, current employer (if applicable), previous employers, and other individuals or entities named herein (and those named on accompanying resume, if any.) I hereby authorize my former employer and other third parties named on this application to release information pertaining to my work record, habits, and performances. In doing so, I hereby release them and the Lutheran Home of Southbury and its agents from all liability which may flow from the release of such information. I understand that if I am hired my employment will be on an at-will basis, for no definite term. As such, I understand that I will enjoy the right to terminate my employment at any time and that Lutheran Home of Southbury will similarly enjoy the right to terminate my employment, at any time, with or without cause. This status can only be modified by a written document setting forth such modification, signed by both me and an authorized representative of Lutheran Home of Southbury. I further acknowledge that I am expected to abide by all Company rules, regulations and policies, written or unwritten, but that such rules, regulations, and policies do not create a contract between me and the Company or otherwise restrict the right of either party to terminate the employment relationship.By adding your name below we will count this as your online signature of approval of the above mentioned agreement. Full NameResumeAccepted file types: pdf, Max. file size: 64 MB.Please attach your resume here.4 + 4 = __* NameThis field is for validation purposes and should be left unchanged.