Concord Care Centers of Ohio | Employment Opportunities

APPLICATION FOR EMPLOYMENT

Federal and state laws prohibit discrimination in employment because of sex, age, race, color, religious creed, marital status, national origin ancestry, disability or handicap.

PERSONAL INFORMATION DATE:

Name:
LAST
FIRST
MI

Address:
STREET
CITY
STATE
ZIP

Telephone:

E-mail:

EMPLOYMENT DESIRED

Position applied for:

Location desired (Check One): Cortland
Hartford
Milan
Sandusky
Toledo

Shift you can work Day Evening Both

Date you can start

Have you ever applied to this company before YES No

If so, when?

Have you ever worked for this company or any other Concord facility before?

Yes No Facility Name

When? Supervisor

Reason for Leaving

EDUCATION

Highest grade completed GRADE SCHOOL
1 2 3 4 5 6 7 8

HIGH SCHOOL
9 10 11 12

COLLEGE
1 2 3 4

Name of last school attended

Vocational or trade training

REFERENCES

Provide three persons not related to you.

NAME
1.
2.
3. ADDRESS

YEARS KNOWN

FORMER EMPLOYERS

List below your work experience, starting with your present or last place of employment.

DATE
EMPLOYED NAME AND ADDRESS
OF EMPLOYER NAME OF
SUPERVISOR POSITION &
SALARY REASON FOR
LEAVING

1. from
      to

2. from
      to

3. from
      to

4. from
      to

5. from
      to

May we contact your employer?   Yes      No

APPLICANT'S STATEMENT
I understand that any employment by this facility will commence with a ninety day training period. If employed by Concord Care Center, I agree to abide by its rules and regulations. The above information is complete and true to the best of my knowledge. I understand that discovery of misrepresentation of omission of facts herin will be cause for immediate dismissal. I authorize this facility to contact any and/or all of my references for full information. I agree to take a physical examination at any time, at the request of this facility and at no personal expense to me, and agree that the examining physician may disclose the finding to this facility or an authorized agent of this facility. I also agree to the sumission of a request for a criminal records check for long-term care workers as required by Senate Bill 160.