Information About You:

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Cell number (If different)

Email

Languages:

What other language(s) do you speak/understand?

General Questions

Which position are you applying for?

CNA
RN
LPN

Referral Source:

Desired Start Date

Employment Details

Are you presently legally authorized to work in the United States of America on a full-time basis?

Yes
No

Are you able to perform the essential functions of the position?

NOTE: The essential physical functions include the ability to sit, stand, bend, reach, grab, safely lift and transport individuals up to 150 lbs.

Yes
No

Have you ever been employed by Celestial Care before?

Yes
No

If Yes, when?

How many shifts per week are you available to work on a continuous basis?

Do you have reliable transportation?

Yes
No

Can you work day or night shifts?

Day (7a-7p)
Night (7p-7a)
Whatever is Available, I Can Do

Have you ever been involuntarily terminated or asked to resign from a position?

Yes
No

If Yes, When and Where?

Is there any additional information relative to a different name necessary to verify previous work records and references?

Yes
No

If Yes, please explain:

Past Convictions & State Board Details

Have you ever been convicted of a felony or crime?

Yes
No

Do you have any arrest whose outcomes are still pending?

Yes
No

If Yes to either question, please explain:

Has your license ever been under investigation, suspended, or been subject to any disciplinary action by any state board?

NOTE: A "Yes" answer to any of the previous three questions will not necessarily disqualify you for employment. A conviction or a pending arrest will be considered only as it is relevant and/or related to the job in question, and will therefore require further investigation and more in-depth discussion before an employment decision can be reached.

Yes
No

If Yes, please explain:

Specialty Skills & Qualifications

Please list any skills or qualifications that may help in the employment hiring process:

Please list if there are any other pertinent (job-related) information, which will help us evaluate you for the job you are seeking?

References

Reference 1 Name

First Last

Relationship:

City and State:

Phone Number:

Reference 2 Name:

First Last

Relationship:

City and State:

Phone Number:

Education/Certifications

High School Name:

Completed?

Yes
No

Diploma, Degree, or GED obtained?

Yes
No

College Name:

Number of Years Completed?

1
2
3
4

Diploma or Degree obtained?

Yes
No

Course of Study?

Any other certifications?

Yes
No

If Yes, please specify:

Current Employment Details

Are you currently employed?

Yes
No

May we contact your current employer?

Yes
No

Current or Most Recent Employer/Company:

Company Phone Number:

City and State:

Reason For Leaving:

Supervisor - Name & Title:

Ending Salary:

Start Date (Month/Year):

End Date (Month/Year):

Position Title - Describe Duties:

Previous Employer/Company:

Fill in information about the employer you had prior to your most recent employer.

Company Phone Number:

City and State:

Reason For Leaving:

Supervisor - Name & Title:

Ending Salary:

Start Date (Month/Year):

End Date (Month/Year):

Position Title - Describe Duties:

Please explain in detail any gaps in your employment history:

Disclaimer

I hereby certify that all statements made in this application are true and correct to the best of my knowledge and belief. I understand and agree that any misrepresentation or omission of facts in my application may be justification for refusal to hire, or termination of employment. I further understand that, prior to or after being hired by Celestial Care, an investigative report such as a Background Check and Reference Check may be collected pertaining to the quality and quantity of my work performed. Should a Consumer Report be requested I would be furnished with my rights under the FCRA.

I authorize all past employers, schools, persons and organizations having relevant information or knowledge to provide it to Celestial Care or its duly authorized representatives for its use in deciding whether or not to offer me employment and specifically waive any liability in responding to inquiries in connection with my application. Upon written request by me, within a reasonable period of time, Celestial Care will make available to me the nature and scope of all reports of every type obtained.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Celestial Care, its subsidiaries and affiliates, and me for either employment or for the providing of any benefit. If I am offered and accept employment, I understand that employment with Celestial Care is voluntarily entered into, and the employee is free to resign at will at any time, with or without cause. Similarly, Celestial Care may terminate the employment relationship at will at any time, with or without notice or cause, so long as there is no violation of applicable federal or state law. In signing this form, I certify that I understand all the questions and statements in this application.

First & Last Name:

Typing First & Last Name constitutes an electronic signature.

Date

Name

This field is for validation purposes and should be left unchanged.

RN Application

Information About You:

General Questions

Employment Details

Past Convictions & State Board Details

Specialty Skills & Qualifications

References

Education/Certifications

Current Employment Details

Disclaimer