Application Step 1 of 6 16% Your Personal InformationName* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Best Time To Call You*MorningsEarly AfternoonLate AfternoonEarly EveningDo You Have Access To A Car?* Yes No Are You A U.S. Citizen Or Do You Have A Permit, Which Allow You To Work?* Yes No Position You're Applying ForPosition You're Applying For* If Applying for Certified Nursing Assistant - Are You Over 18? Yes No What Hours Are You Available To Work?* AM PM NOC Which Days Are You Able to Work?* Monday Tuesday Wednesday Thursday Friday Saturday Sunday Which Types Of Employment Interest You?* Permanent Full Time Temporary Full Time Permanent Part Time Temporary Part Time If So, How Long? Education and TrainingSelect The Highest Grade Or Year You Completed in School*12345678910111213141516Do You Have A High School Dipolma Or A GED Equivalency?* Yes No Training Beyond High School (College or University)Name & LocationDate Attended (From and To)Credits EarnedMajor FieldGPA/BaseDegree Conferred and Year Under Credits Earned, indicate Q for Quarter Hours and S for Semester Hours. Other Training Not Listed AboveDescribe any education or training you have had which is not covered above, such as vocational school, correspondence courses, service schools, in-service training or volunteer work which you feel is relevant to the job or jobs for which you are applying. Also include relevant licenses or certificates. (Be Specific.) Lifting?* 25 lbs Or Less 50 lbs 75 lbs 100 lbs Or More For some positions, it may be required that employees possess certain physical capabilities. Check the appropriate box below, which you feel reflect the physical activities in which you can routinely engage without harm to yourself or fellow employees. Please be assured that a negative answer will not disqualify you from consideration. Do You Have Difficulty Bending Or Stooping? Yes No Do You Have Difficulty Climbing?* Yes No Do You Have Difficulty Standing for Long Periods Of Time?* Yes No Do You Have Difficulty Working In Temperature Extremes?* Yes No Have You Ever Been Convicted Of Any Violations Other Than Minor Traffic Violations?* Yes No For What Have You Been Convicted, When And Where?IF THERE ARE ANY EXTENUATING CIRCUMSTANCES OF WHICH WE SHOULD BE AWARE, PLEASE STATE THIS. (Existence of a criminal record does not constitute an automatic bar to employment and your record will be considered only as it may substantially relevant to the job for which you are applying). *FAILURE TO DISCLOSE CONVICTIONS MAY SUBJECT YOU TO TERMINATION IF HIRED OR ELIMINATE YOU FROM CONSIDERATION IF NOT YET HIRED. Work ExperienceProvide a complete description. This information will be used to determine if your application is accepted. Be specific. Start with your most recent job. BE CERTAIN TO INCLUDE SERVICE IN THE ARMED FORCES. For part-time work, show the average number of hours per month. Indicate any job changes in job title under the same employer as a separate position. Employer 1* Job Title PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment Date From MM slash DD slash YYYY Employment Date To MM slash DD slash YYYY Please List Your Job DutiesStarting Wage Ending Wage Reason For Leaving Name / Title of Immediate Supervisor Employer 2* Job Title PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment Date From MM slash DD slash YYYY Employment Date To MM slash DD slash YYYY Please List Your Job DutiesStarting Wage Ending Wage Reason For Leaving Name / Title of Immediate Supervisor Employer 3* Job Title PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment Date From MM slash DD slash YYYY Employment Date To MM slash DD slash YYYY Please List Your Job DutiesStarting Wage Ending Wage Reason For Leaving Name / Title of Immediate Supervisor Employer 4* Job Title PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment Date From MM slash DD slash YYYY Employment Date To MM slash DD slash YYYY Please List Your Job DutiesStarting Wage Ending Wage Reason For Leaving Name / Title of Immediate Supervisor Personal ReferencesReference 1 - First and Last Name* First Last PhoneEmail Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference 2 - First and Last Name* First Last PhoneEmail Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference 3 - First and Last Name* First Last PhoneEmail Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code List Any Additional Information You Would Like Us To Consider. Information AuthorizationI hereby authorize the Human Resource Department of Pine Valley Community Village to investigate without liability the information supplied by me in my application for employment including academic, occupational, health, police and governmental records. I also authorize listed past employers and personal references to make full response without liability to any inquiries by the Human Resource Department of this long-term care facility in connection with this application for employment. Typed name will be considered as signature.Signature* Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Δ
