Employment Application

If you are a licensed professional, please provide your certification/license number and the state in which you are licensed.
CNA LPN RN OT PT SLP Other If other, please explain:	Certification/License #:	State:
Year you first obtained certification/license:	Expiration Date:  CalendarNow(UTC - 05:00)

Check all the jobs you are interested in:
If other, Please explain:

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Check Schedule you can work:

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Shift Preference:

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Prefer:

Nursing HomesAssisted LivingAdult Day HealthPost-AcuteOpen

Personal Information:

* First Name:				* Last Name:
* Address:				Address (Cont.):
* City:				* State:
				* Zip:
Cell Phone:	( ) - Second three digits Last four digits			* Telephone #:	( ) - Second three digits Last four digits
* E-mail Address:

Do you have a valid New Jersey driver's license? (Only applicable to positions that require driving Company vehicles):

YesNo

Are you over 18 years old?:

YesNo

Required salary amount $:
Upload your resume:
Desired Start Date:

Are you legally eligible for employment in the United States?:

YesNo

Did you ever work or attend school under another name?:

YesNo

If yes, please provide name:  

Working for Parker:

Have you ever worked for or volunteered at Parker Homes?:

YesNo

If yes, please provide dates and job title or volunteer activity:

Have you filled out an application for Parker Home before:

YesNo

Who referred you to Parker Home?:  

Are you related to anyone currently employed by Parker Home:

YesNo

If so, please provide name, relationship, and contact information.:

To the best of your knowledge, are you physically and mentally able to perform the duties of the position for which you have applied:

YesNo

If no, please explain:

Military Service:

Military Service:

YesNo

Branch:

From: To:

Honorable Discharge:

Yes No

If no, please explain.:

Education:

Name and Location of School	Major Subject	Degree/Certificate	Completed yes/no

Your strengths:  
Your weakness:  
Long range goals:  

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Employment History

Please provide 7 years of employment history.

Current Employer:
Phone:	( ) - Second three digits Last four digits
Your Salary $:
Address:
City:
State:
Zip:
Job Title & Responsibilities:
Supervisor's Name & Title:
Reason for Leaving:
Dates of Employment	From:  CalendarNow(UTC - 05:00)
	To:  CalendarNow(UTC - 05:00)

May we contact your current employer for a reference?:

Yes No

Past Employer 1:		Past Employer 2:
Phone:	( ) - Second three digits Last four digits	Phone:	( ) - Second three digits Last four digits
Your salary $:		Your Salary $:
Address:		Address:
City:		City:
State:		State:
Zip:		Zip:
From:	CalendarNow(UTC - 05:00)	From:	CalendarNow(UTC - 05:00)
To:	CalendarNow(UTC - 05:00)	To:	CalendarNow(UTC - 05:00)
Job Title & Responsibilities:		Job Title & Responsibilities:
Supervisor's Name & Title:		Supervisor's Name & Title:
Reason for Leaving:		Reason for Leaving:

Have you had more jobs than those listed above:

YesNo

If yes, how many more years of work history?:  
How many years of job experience do you have in health care?:  

References:

First Name:		First Name:
Last Name:		Last Name:
Phone:	( ) - Second three digits Last four digits	Phone:	( ) - Second three digits Last four digits
Relationship:		Relationship:

First Name:
Last Name:
Phone:	( ) - Second three digits Last four digits
Relationship:

I certify that the information provided above is true and complete to the best of my ability and I understand and agree that any misinterpretation or omission on this application or related papers, or made during an oral interview may result in refusal of employment or be considered as grounds for dismissal.:
* [Please Initial]:
Parker Home may make an investigation of my history and may verify all data provided in this application, related papers or an oral interview. I allow such investigation and release from liability, Parker Home/ or any person or company giving or refusing such information.:
* [Please Initial]:
I understand that this application is not, and is not intended to be contract of employment; and that, if hired, my employment is 'at-will', for no definite period and may be ended at any time without prior notice, without liability for wages, salary or any benefits except those earned up to the date of separation. if employed by parker, I agree to undergo medical examinations at any time at the option of Parker. I also understand and agree that I will abide by Parker's rules and regulations. I read, understand and agree to the above.:
* [Please Initial]:

* Signature:	Date:   CalendarNow(UTC - 05:00)

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