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In compliance with federal and state equal employment opportunity laws, qualified applicants are considered for all positions
without regard to race, color, religion, gender, national origin, age, disability, sexual orientation, marital or veteran status,
or any other legally protected status. It is unlawful in Massachusetts to require or administer a lie detector test as a condition
of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.
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| PERSONAL INFORMATION |
| Date of Application
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SS Number
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First
Name
Middle
Last Name
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Address
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City
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State
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Zip Code
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Home Phone:
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Mobile Phone:
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| Email:
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| OCCUPATIONAL OBJECTIVES |
| Position applied for:
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Salary Required:
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Shifts Available: Day
Evening
Night
Weekends
Full-time
Part-time
When can you start? :
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| What is your occupational goal? :
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| PLEASE ANSWER THE FOLLOWING |
Referral Source: Name of paper:
Name of website:
Employee Referral Name :
Other:
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| If you are under 18 years of age, can you provide required proof of your eligibility to work? : Yes
No |
| Have you ever been employed at Notre Dame Long Term Care Center? : Yes
No |
| If yes, please give dates: From:
To: |
| Do you have any relatives in our employ? : Yes
No |
| If yes, please give dates: From:
To: |
| Do you have any scheduling limitations? Yes
No |
| If yes, please explain: scheduling limitations:
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| Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? : Yes
No (Proof will be required upon employment.) |
| EDUCATIONAL BACKGROUND |
| High School Name/Address of School
Course of Study Years
Diploma/Degree |
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| College Name/Address of School
Course of Study Years
Diploma/Degree |
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| Other Name/Address of School
Course of Study Years
Diploma/Degree |
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| Please list Professional Registration, License or Certification including state of issue and number.
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| EMPLOYMENT EXPERIENCE |
| Start with your present or last job. In conformance with Mass. Laws, chapter 149,
verifiable work performed on a volunteer basis may be included as work experience. You may exclude organizations which
indicate race, color, religion, gender, national origin, sexual orientation, disabilities or other protected status if you wish.
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| Employer Name |
Dates Employed
From:
To: |
| Address |
Starting Wage
Ending Wage |
| Phone # |
Supervisor's Name,phone and e-mail address:
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| May we contact the Supervisor for reference? : Yes
No Later |
| Employer Name |
Dates Employed
From:
To: |
| Address |
Starting Wage
Ending Wage |
| Phone # |
Supervisor's Name,phone and e-mail address:
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| May we contact the Supervisor for reference? : Yes
No Later |
| Employer Name |
Dates Employed
From:
To: |
| Address |
Starting Wage
Ending Wage |
| Phone # |
Supervisor's Name,phone and e-mail address:
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| May we contact the Supervisor for reference? : Yes
No Later |
| It is the policy of Notre Dame Long Term Care Center (NDLTCC) to require all employees to share day, evening, night,
weekend and holiday duties in accordance with the requirements of the department to which they are assigned, and to reassign
employees in accordance with the needs of the department. Employees are expected to report to work regardless of
weather conditions. I understand and accept this as a condition to my employment. I agree to have a physical exam
including necessary tests, which I must pass before starting employment.
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| Date: |
Signed:
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| Please read carefully before signing: |
| I agree to conform to the rules and regulations of Notre Dame Long Term Care Center (NDLTCC).
I understand that my employment may be terminated at any time for any reason at the option of either myself or NDLTCC.
I hereby affirm the information on this application is true and complete. I further understand that a criminal background
check will be part of the verification process and that all employment history information may be checked.
I recognize that employment at NDLTCC is conditional upon presentation of documentation of authorization to work as
required by Immigration Reform and Control Act. Failure to produce these documents within the first three days of
employment may result in my termination. I understand that if I accept employment it is with the express understanding
that continued employment is at the complete discretion of NDLTCC. I understand that NDLTCC is a "No Smoking Facility"
and failure to comply with the no smoking policy may be grounds for disciplinary action up to and including termination.
I declare that all of the statements on this application are true to the best of my knowledge and that any false or
misleading representations or omissions may disqualify me from further consideration for employment and may result
in termination even if discovered at a later date. |
| Date: |
Signed:
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REFERENCES for EMPLOYMENT
(Please provide 3 references, preferably present or former supervisors) |
Your Name: | Position:
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| I authorize Notre Dame Health Care Center and/or its agents to conduct an investigation
of my application for employment as considered necessary. I authorize and request any and all former employers and/or businesses
reference to furnish information concerning my past job performance and work histories.
I release from any liability the individuals and businesses named below furnishing such information.
I recognize a photocopy of this authorization is a valid requisition. I understand that any false statements
on my application are grounds for dismissal or withdrawal of any offer of employment. |
Signature: | Date:
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| REFERENCE 1 Check one: Supervisor Co-worker |
Name: | Title:
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| Company Name: |
| Address: |
Phone # | e-Mail
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| REFERENCE 2 Check one: Supervisor Co-worker |
Name: | Title:
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| Company Name: |
| Address: |
Phone # | e-Mail
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| REFERENCE 3 Check one: Supervisor Co-worker |
Name: | Title:
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| Company Name: |
| Address: |
Phone # | e-Mail
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