Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Are you allergic to any of the following? * *

Please select all that apply

Cigarette smoke

Pet dander

Other

When are you available to work? * *

Please check all that apply.

Days

Nights

Weekends

Holidays

On-call

*If your availability changes, it is your responsibility to submit a written request of change to your supervisor. The change will be observed upon approval by management with an identified date. I understand that the emergency conditions may require me to temporarily work times other than those for which I am applying and agree to such scheduling change as directed by my supervisor or administrator of this agency. * *

I agree

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 pre-employment physical examination/competency test and such future examinations as may be required by this institution at such times and places as the institution shall designate. I understand that I will be required to follow the personnel policies and rules of the institution and that infractions of said rules may lead to dismissal. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. I further understand that this institution follows the “fair employment practice code” and there is no discrimination in the hiring of individuals based on sex, race, religion, age, or physical or mental handicap unrelated to the ability to perform the work required. I understand that if I am employed it will be on a probationary or trial basis for a period of 90 days. Upon my termination I authorize the release of reference information on my work. * *

I agree