SOUTH OAKS HOSPITAL BROADLAWN MANOR NURSING HOME 400 Sunrise Highway Amityville, NY 11701
THE LONG ISLAND HOME
Title VII of the Civil Rights Act of 1964 prohibits discrimination based on race, color,
A Member of the North Shore-‐LIJ Health System
EMPLOYMENT APPLICATION
religion, sex, citizenship, age, handicap or disability, pregnancy and marital status.
EQUAL OPPORTUNITY EMPLOYER
PLEASE COMPLETE THIS FORM AND FAX IT TO: (631) 264-3801 Position Desired ___________________________________ Are You Interested in Hours Preferred Day Evening Night
Full Time Part Time
On Call/Per Diem Temporary
Name ______________________________________________________________________________________________________ First M. Last Address ____________________________________________________________________________________________________ City State Zip Code Social Security Number________________________________________________ Phone Number ________________________ How did you find out about us?_________________________________________________________________________________ Were you previously employed by us?
Yes
No
Do you have a legal right to work in the U.S.?
Yes
No
If yes, when __________________________________
*Proof of lawful employment eligibility in the United States will be required upon employment, in accordance with the Immigration Reform and Control Act of 1986.
Are you related to anyone in our employ?
Yes
No
If yes, state name of individual ___________________________
What is your approximate salary requirement? $______________
RECORD OF EMPLOYMENT (Begin with most recent and include summer jobs)
FILL IN ALL SECTIONS Present or Last Employer __________________________________________________________ From _________________to _______________ Month
Year
Month
Year
Address __________________________________________________________________Phone Number __________________________ City
State
Zip Code
Your Position ______________________________________________ Base Salary ____________________________________
Hours of Work ___________________________
Reason for Leaving ______________________________________________
Employer _____________________________________________________________
From ________________ to _________________ Month
Year
Month
Year
Address __________________________________________________________________ Phone Number __________________________ City
State
Zip Code
Your Position ______________________________________________ Base Salary ____________________________________
Hours of Work___________________________
Reason for Leaving ______________________________________________
Employer ________________________________________________________________From__ ______________ to ________________ Month Year Month Year Address __________________________________________________________________Phone Number __________________________ City
State
Your Position ______________________________________________ Base Salary ____________________________________
Zip Code
Hours of Work __________________________
Reason for Leaving _____________________________________________
EDUCATION Undergraduate College/University
High School
School Name and Location Years Completed Diploma/Degree Course of Study
9
10
11
12
1
2
3
4
Graduate
1
2
3
Certificate/ Technical
4
List any scholastic honors you have received, any specialized training programs, apprenticeships or courses, or any memberships in professional organizations you consider relevant to the position you are seeking: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ SKILLS/ QUALIFICATIONS Type ______ wpm
(If relevant to the position for which you are applying)
_____ Familiarity with medical terminology - Other______________(office, word processing, etc.)
CPR Certified? ( ) Yes ( ) No NURSES
RN
Expiration date_________________ Issued by _____________________
LPN
Do you possess a current N.Y.S. Registration? ( ) Yes ( )No
Registration # _________________ If no, please complete the following:
Have you taken N.Y.S. Boards? ( )Yes ( )No Date when scheduled ___________________________ Do you possess current out-of-state registration? ( ) Yes ( ) No If yes: State_______________ Registration #___________________ Have you applied for N.Y.S. Registration: ( ) Yes ( ) No
If yes: Date scheduled ____________________________
NURSING ATTENDANTS Are you N.Y.S. Certified? ( ) Yes ( ) No
Certification # _______________________________ If no, please complete the following:
Have you scheduled or taken the examination? Indicate Date ______________________________ MILITARY SERVICE RECORD Were you in the U.S. Armed Forces? ( ) Yes ( ) No
If yes, what Branch? _____________________________________
List job duties, including special training _________________________________________________________________ MISCELLANEOUS Have you ever been convicted of a violation of any criminal offense? (Do not include parking violations) ( ) Yes
( ) No
If yes, please explain. Conviction of a crime will not necessarily preclude your employment with the Hospital/Nursing Home. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Have you ever worked for South Oaks Hospital/Broadlawn Manor Nursing Nursing Home under a different name? ( ) Yes ( ) No If yes, what name? ___________________________________________________ Is additional information relative to change of name or nickname necessary to check on your references? ( ) Yes ( ) No If yes, please explain ________________________________________________________________________________
CONDITIONS OF EMPLOYMENT I understand that in applying for employment I must comply with all policies and procedures of South Oaks Hospital/ Broadlawn Manor Nursing Home, and that employment is contingent upon satisfactory reference verification and passing the pre-employment physical examination. The facts set forth in my application are true and complete, to the best of my knowledge. I further understand that any false statements or misrepresentations made by me on this application or any supplement will be sufficient grounds for dismissal. I hereby authorize you to make any investigation necessary to verify the information provided in this application and I release the Hospital/Nursing Home from any and all liability that might arise from such investigation. Further, I authorize my previous employers to release any and all employment information concerning me to the Hospital/Nursing Home, and I release them from any and all liability that might arise from the release of my employment records. Further, if employed, I understand and agree that my employment is for no fixed or definite period, and that I may be terminated at any time for any or no reason, subject to applicable law.
____________________________________________________________________________________
Applicant's Signature
Date
NOTE: This application cannot be considered without your signature.
____________________________________________________________________________________________________________ (DO NOT WRITE BELOW THIS LINE - HUMAN RESOURCES DEPARTMENT TO COMPLETE)
Interviewed by (HR): ___________________________________________________ Date : ____________________ Dept Interviewer:________________________________________________________________________________ Remarks : ________________________________________________Approved for Hire: Yes ( )____No ( )_____ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
F:\USERS\MALLISON\hr forms\NEW HIRE\application.doc Rev: 6/06,11/07,7/08,9/09,2/12, 3/12
