THE CIVIL RIGHTS ACT OF 1964 PROHIBITS DISCRIMINATION BECAUSE OF RACE, COLOR, SEX, RELIGION OR NATIONAL ORIGIN. PUBLIC LAW 90 702 PROHIBITS DISCRIMINATION BECAUSE OF AGE. THE LAWS OF SOME STATES PROHIBIT SOME OR ALL OF THE ABOVE TYPES OF DISCRIMINATION.

TODAY’S DATE / NAME (FIRST, MIDDLE, LAST) / SOCIAL SECURITY NUMBER
ADDRESS (NUMBER, STREET, CITY, STATE, ZIP) / PHONE NUMBER
FOR WHAT POSITION ARE YOU APPLYING?
WHAT SPECIAL TRAINING DO YOU HAVE IN THIS AREA?
FULL TIME______PART TIME______HOURS EXPECTED______SALARY REQUIREMENTS______
SHIFTS AVAILABLE 1ST____ 2ND ____ Midnights____ HIGH SCHOOL: 1 2 3 4 GED COLLEGE: 1 2 3 4
LICENSE/CERTIFICATION YES NO TYPE: ______STATE______LICENSE #:______
LIST EMPLOYEE HISTORY FOR THE PAST 10 YEARS (MOST RECENT FIRST)
Employee Name, Address, Phone / DATES / POSITION / SALARY / REASON FOR LEAVING

PERSONAL/PROFESSIONAL REFERENCES

NAME ADDRESS PHONE

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EMERGENCY NOTIFICATION:

NAME:______ADDRESS:______

DAYTIME PHONE:______EVENING PHONE:______

I HEREBY CERTIFY THAT THE INFORMATION CONTAINED ON THIS APPLICATION FORM IS TRUE AND ACCURATE. I AUTHORIZE SOUTHGATE NURSING & REHABILITATION CENTER TO CONTACT ANY OF MY SCHOOLS, FORMER EMPLOYERS EXCEPT THOSE I HAVE INDICATED, OR PERSONS DEEMED NECESSARY, FOR A COMPLETE ACCOUNT OF THEIR EXPERIENCE WITH ME. I UNDERSTAND THAT IF I AM EMPLOYED, ANY MISREPRESENTATION OF RELEVANT FACTS ON THIS APPLICATION FORM IS SUFFICIENT CAUSE FOR DISMISSAL. I ALSO UNDERSTAND THAT I WILL BE REQUIRED TO SUCCESSFULLY COMPLETE A MEDICAL EXAMINATION BEFORE EMPLOYMENT.

DATE:______SIGNATURE:______

RELEASE

I UNDERSTAND THAT IF EMPLOYED BY SOUTHGATE NURSING & REHABILITATION CENTER, MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE, AT THE OPTION OF EITHER SOUTHGATE NURSING & REHABILITATION CENTER OR ME. I ALSO UNDERSTAND THAT NEITHER THIS APPLICATION, NOR ANY COMMUNICATION BY A MANAGEMENT REPRESENTATIVE IS INTENDED TO CREATE OR CREATES A CONTRACT FOR EMPLOYMENT OR A GUARANTEE OF BENEFITS. I ALSO UNDERSTAND AS PART OF THE NEW HIRE PROCESS, A DRUG SCREEN IS REQUIRED BEFORE EMPLOYMENT CAN BEGIN.

I UNDERSTAND THAT, AS PART OF THE APPLICATION PROCESS FOR A NURSE AIDE POSITION, SOUTHGATE NURSING & REHABILITATION CENTER WILL VERIFY WITH THE STATE NURSE AIDE REGISTRY MY COMPETENCY AND CERTIFICATION AS A NURSE AIDE AND MAY OBTAIN ANY AND ALL INFORMATION CONTAINED IN THE REGISTRY FOR USE IN EVALUATING MY APPLICATION FOR EMPLOYMENT.

I ALSO UNDERSTAND THAT IF EMPLOYED, I HAVE 10 DAYS TO COMPLETE FEE-APP BACKGROUND CHECK IF I HAVE NOT ALREADY DONE SO, AS REQUIRED BY IL DEPT. OF PUBLIC HEALTH. MY EMPLOYMENT STATUS WILL BE CONDITIONAL UPON THE RESULTS OF THIS BACKGROUND CHECK.

I HEREBY AUTHORIZE SOUTHGATE NURSING & REHABILITATION CENTER TO VERIFY ALL INFORMATION PROVIDED ON THE APPLICATION AND/OR IN THE INTERVIEW, AS WELL AS CONTACTING MY FORMER EMPLOYERS AND REFERENCES. I HEREBY RELEASE SOUTHGATE NURSING & REHABILITATION CENTER AND OTHERS PROVIDING SUCH INFORMATION FROM ALL LIABILITY WHATSOEVER RESULTING FROM THE DISCLOSURE OF SUCH INFORMATION.

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APPLICANT SIGNATURE DATE

FOR OFFICE USE ONLY
INTERVIEWER’S NOTES:______
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HIRING DATA:
POSITION:______SHIFT:______STATUS: FT______PT______ON CALL______(HRS PER PAY PERIOD)______
DEPARTMENT:______START DATE:______BASE HOURLY RATE:______
APPROVED:
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PERSONNEL DIRECTOR DATE
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DEPARTMENT HEAD DATE
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ADMINISTRATOR DATE