Job Application - Our Lady of Hope

Application for Employment

We are an Equal Opportunity Employer. We consider applicants for all positions without regard to race, color, religion, sex, gender identity, sexual orientation, national origin, age, family/parental status, marital or veteran status, disability, or any other legally protected status. This application will only be considered for the specific position applied for and will only be considered for 60 days. If the position applied for has not been filled and 45 days have passed, you will have to reapply. If you need help or accommodation completing the application, please contact the business office.

1Contact Information

2Eligibility Information

3Education

4Employment History

5Applicant

Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Position Applied for

Salary Desired

How Did You Learn About Us?

Employment Agency

Word of Mouth

Current Employee

Walk-In

Other

If "Other", please specify

Are you over 18 years of age? You may not be eligible for certain positions and may be required to provide certain proof of your eligibly to work.

Yes

Have you ever filed an application with us or another community where CSM is the management agent?

Yes

If Yes, give date & name of community:

Have you ever been employed with us before?

Yes

If Yes, give date

Are you currently employed?

Yes

May we contact your present employer?

Yes

Failure to allow us to contact an employer may lead you to being considered not eligible for hire.

Are you legally eligible for employment in the United States?

Yes

Proof of legal eligibility for employment will be required.

On what date would be you available for work?

MM slash DD slash YYYY

Are you available to work:

Full Time

Part Time

Shift Work

Temporary

Preferred working shift:

Nursing department positions only: Preferred Unit(s)

Assisted Living

Memory Care

Long-term Nursing

Check all that apply

This field is hidden when viewing the form

Education

Education will only be considered if an essential function of the job.

Education

Education will only be considered if an essential function of the job.

High School

School Name and Location

Highest Year Completed

Describe Course of Study: Please list all degrees/certifications/ diplomas/apprenticeships/ specialized training you have received.

Describe any honors you have received which are relevant to the position you are seeking.

Post High School

School Name and Location

Years Completed

Describe Course of Study: Please list all degrees/certifications/ diplomas/apprenticeships/ specialized training you have received.

Describe any honors you have received which are relevant to the position you are seeking.

Graduate/Professional

School Name and Location

Years Completed

Describe Course of Study: Please list all degrees/certifications/ diplomas/apprenticeships/ specialized training you have received.

Describe any honors you have received which are relevant to the position you are seeking.

Licensed/Certified Applicants

License Number

Type of license/certification held

State license issued by:

As a licensed/certified professional, have you ever had action taken against you, had your license revoked or suspended, or have you been denied a license in a health-related field.

Yes

If yes, describe

If you have additional post high school degrees, certifications, diplomas, apprenticeships, or specialized training, please outline them below.

Employment References

Give name, address and telephone number of three supervisory references.

Reference 1

Reference Name

Title

Company

Telephone Number

Reference 2

Reference Name

Title

Company

Telephone Number

Reference 3

Reference Name

Title

Company

Telephone Number

Have you ever been convicted of a felony, misdemeanor, or a law violation other than a minor traffic violation?

Yes

Conviction will not automatically bar you from employment, unless it is a “Barrier Crime” as defined by applicable law. The date, nature, and the relationship of the conviction to the position sought will be considered.

If Yes, please explain

Employment Experience

Start with your present or last job. Include any Job-related military service assignments and volunteer activities. Each applicant must complete this section, “See Resume” is not sufficient

#1 Employment Experience

Employer 1

Employer Name

Employer Address

Telephone Number

Employer 1

Work Performed

Job Title

Supervisor

Employer 1

Starting Date

Ending Date

Starting Salary

Ending Salary

Reason for Leaving

Can we contact this employer?

Yes

#2 Employment Experience

Employer 2

Employer Name

Employer Address

Telephone Number

Employer 1

Work Performed

Job Title

Supervisor

Employer 1

Starting Date

Ending Date

Starting Salary

Ending Salary

Reason for Leaving

Can we contact this employer?

Yes

#3 Employment Experience

Employer 2

Employer Name

Employer Address

Telephone Number

Employer 1

Work Performed

Job Title

Supervisor

Employer 1

Starting Date

Ending Date

Starting Salary

Ending Salary

Reason for Leaving

Can we contact this employer?

Yes

#4 Employment Experience

Employer 2

Employer Name

Employer Address

Telephone Number

Employer 1

Work Performed

Job Title

Supervisor

Employer 1

Starting Date

Ending Date

Starting Salary

Ending Salary

Reason for Leaving

Can we contact this employer?

Yes

If you'd like to upload your resume or additional work history, please upload a pdf or word documents:

Accepted file types: pdf, doc, docx, Max. file size: 5 MB.

Applicant’s Statement

Applicant Statement

I have read and agree with this Applicant Statement

I certify that answers given herein are true and complete to the best of my knowledge and I certify that I am an authentic job seeker.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days and only for the position sought. Applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time and reapply if necessary.

I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future for any specific duration and that my employment is at will.

If you decide to contact my previous employers or engage an investigative consumer reporting agency to report on my credit and personal history, I authorize you to do so and I understand that will receive additional information and authorizations on such reports as required by law.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.

Signature

Date

MM slash DD slash YYYY

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