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Roberto Muñiz
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Employment Application
Applicants are considered for all the positions without regard to race, color, religion, gender, sexual orientation, age, citizenship or a non-job related disability or handicap:
Fields marked by * are required
Today's Date:
Calendar
Now
(UTC - 05:00)
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:
Calendar
Now
(UTC - 05:00)
Check all the jobs you are interested in:
Dining Assistant
Cook
Laundry
Housekeeper
Maintenance
Administrative
Rehabilitation
Recreation
Management
Nurse
Social Worker
Other
If other, Please explain:
Check Schedule you can work:
Full time
Part time
Doesn't matter
Weekends ok
Weekends NOT ok
Shift Preference:
7am-3pm
3pm-11pm
11pm-7am
Other
Open
Prefer:
Nursing Homes
Assisted Living
Adult Day Health
Post-Acute
Open
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):
Yes
No
Are you over 18 years old?:
Yes
No
Required salary amount $:
Upload your resume:
Desired Start Date:
Calendar
Now
(UTC - 05:00)
Are you legally eligible for employment in the United States?:
Yes
No
Did you ever work or attend school under another name?:
Yes
No
If yes, please provide name:
Working for Parker:
Have you ever worked for or volunteered at Parker Homes?:
Yes
No
If yes, please provide dates and job title or volunteer activity:
Have you filled out an application for Parker Home before:
Yes
No
Who referred you to Parker Home?:
Are you related to anyone currently employed by Parker Home:
Yes
No
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:
Yes
No
If no, please explain:
Military Service:
Military Service:
Yes
No
Branch:
From:
Calendar
Now
(UTC - 05:00)
To:
Calendar
Now
(UTC - 05:00)
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:
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:
Calendar
Now
(UTC - 05:00)
To:
Calendar
Now
(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:
Calendar
Now
(UTC - 05:00)
From:
Calendar
Now
(UTC - 05:00)
To:
Calendar
Now
(UTC - 05:00)
To:
Calendar
Now
(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:
Yes
No
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:
Calendar
Now
(UTC - 05:00)
*
Parker Awards