Name: Schofield Care
Address: NY

To Applicant: We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. Please make sure to fill out each required field. A clear understanding of your background and work history will aid us in placing you in the position that best meets your qualifications and may assist us in possible future upgrading. STATE AND FEDERAL LAWS PROHIBIT DISCRIMINATION ON THE BASIS OF RACE, COLOR, MARITAL STATUS, CREED, SEX, NATIONAL ORIGIN, SPONSOR, DISABILITY, HANDICAP, AGE, VETERAN STATUS, OR SEXUAL PREFERENCE. Upon completion of this application, you should receive an email confirming your submission. If no confirmation email is received, please email hr@schofieldcare.org with details about your application.

Resumé

First Name

Middle Name

Last Name

Email

Primary Phone

Secondary Phone

Are you at least 18 years of age?

Yes

No

If no, what is your date of birth?

Rate of pay expected: $

Availability (check all that apply)

Full Time

Part Time

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Number of hours per week

Please enter a value between 5 and 60.

I'm available

Anytime

At specific times

If your application is considered favorably, on what date will you be available for work?

What prompted you to apply here for employment?

If employee referral or Other, please specify who or what prompted you to apply

Were you previously employed by us?

Yes

No

If yes, when? And Position?

Please list any experiences, skills or qualifications that you feel would especially fit you for work with our organization

Do you possess a valid New York State Driver’s License?

Yes

No

Month and year of your last physical examination

Family physician:

First Name

Last Name

Employment Record

Do not need to complete if Resume is attached.

Most Current

Employer

Phone

Title/Position Held

Supervisor/Title

Start Month/Year AND End Month/Year or Current

Last Hourly Pay Rate:

Reason for Leaving

Summary of Responsibilities

2

Employer

Phone

Title/Position Held

Supervisor/Title

Start Month/Year AND End Month/Year or Current

Last Hourly Pay Rate

Reason for Leaving

Summary of Responsibilities

3

Employer

Phone

Title/Position Held

Supervisor/Title

Start Month/Year AND End Month/Year or Current

Last Hourly Pay Rate

Reason for Leaving

Summary of Responsibilities

4

Employer

Phone

Title/Position Held

Supervisor/Title

Starting Pay Rate

Last Hourly Pay Rate

Reason for Leaving

Summary of Responsibilities

May we contact all employers listed above / on resume?

Yes

No

N/A

If No, Indicate by number which ones you do not want us to contact

Is additional information, relative to a change of name, necessary to enable a check on your work record?

Yes

No

If Yes, Please Explain

Have you ever collected unemployment insurance benefits?

Yes

No

If Yes, When? For how long?

Have you ever been convicted of any felony, misdemeanor, or other offense?*

Yes

No

If Yes, This does not automatically disqualify you for employment. Please provide details

Have you ever been convicted of resident/patient abuse?

Yes

No

If Yes, Please provide details

Have you ever worked/had a professional license or certification in another state?

Yes

No

If Yes, Which state(s)?

School Record

Highest Level of Education Completed

Number of years attended

Please enter a value between 1 and 8.

Did you graduate?

Yes

No

If you possess specialized training, please explain in full

Nurses, CNA's and Technicians - Registration Number

Registration expiration date

Registration State

Are you Interested in any other positions at Schofield

The facts set forth in my application are true and complete. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal. Schofield is hereby authorized to make any investigation of my personal history. I authorize the representatives of Schofield Residence and its affiliates to contact my present and former employers and all personal references listed. I understand that I must pass a physical examination and provide sufficient proof under the Immigration Reform Act that I am eligible for employment. I recognize and agree that I am not being employed for any set period of time; I can terminate my employment at any time and Schofield Residence and its affiliates reserve the right to do the same.

Applicant Signature

Reset

by signing here, you are agreeing to the above statements.

LPN Med Pass

Job Description

Employment Record

School Record