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MCLEAN COUNTY NURSING HOME 901 NORTH MAIN STREET NORMAL, IL 61761 (309) 888-5380 APPLICATION FOR EMPLOYMENT OF POSITION APPLYING Professional license, registration, or certification number, if DRIVER’S LICENSE ARE YOU 18 YEARS OF AGE OR OLDER? NO SOCIAL SECURITY PRESENT PHONE NUMBER WHERE YOU CAN BE EMPLOYMENT DESIRED: FULL PART WHAT SHIFT ARE YOU APPLYING DO YOU REALIZE THAT IT MAY BE NECESSARY FOR YOU TO WORK ON WEEKENDS AND HOLIDAYS? WHEN WILL YOU BE AVAILABLE FOR WORK? HAVE YOU WORKED FOR THIS NURSING HOME BEFORE? IF YES, LIST ANY RELATIVES WORKING FOR US: ARE YOU A CITIZEN OF THE UNITED STATES? WHAT LANGUAGES DO YOU EDUCATION: HIGH attended: ---PAGE BREAK--- I understand that any false statements made as a part of this application will be considered sufficient cause for dismissal. I also understand that my employment is contingent upon the results of my physical examination and my references. I authorize McLean County Nursing Home to make reference checks with my former employers, and I release my former employers from any liability for information concerning my employment record. I understand that such information will be considered strictly confidential and used only to assist in determining my suitability for employment. I also autho rize the release of information concerning my employment in this facility, and I release the facility and its employees from any liability for employment information given for employment, housing or credit references. I understand that I will be on a probationary basis for 6 months from the date of employment. Signature of applicant Date FOR OFFICE USE ONLY INTERVIEWER DATE RESULTS OF REFERENCE CHECKS: INITIALS EMPLOYER COMMENTS OF CALLER_______ PERSONAL REFERENCES: Determination of Department Starting It is the policy of the McLean County Nursing Home to afford equal, opportunity to all employees and applicants regardless of race, color, religion, sex, age, national origin or handicap. ---PAGE BREAK--- EMPLOYMENT: ARE YOU PRESENTLY EMPLOYED? YES NO EMPLOYMENT HISTORY: (Please start with present or most recent employer) 1. NAME OF STARTING DATE:__________DATE LEFT:__________SUPERVISOR’S REASON FOR MAY BE CONTACTED: 2. NAME OF STARTING DATE:__________DATE LEFT:__________SUPERVISOR’S REASON FOR MAY BE CONTACTED: Other training or experience you have had which qualifies you for the position for which you are applying may be listed on the back of the last page of this application. Do you have any physicial or mental condition, which may impair your ability to safely and efficiently perform the job for which you are applying? NO PERSONAL REFERENCES: (Do not include former employers or relatives) 1. 2. HAVE YOU EVER BEEN CONVICTED OF A CRIME? IF YES, PLEASE EXPLAIN BELOW: WHY DO YOU WANT TO WORK IN THE POSITION FOR WHICH YOU ARE APPLYING? ---PAGE BREAK--- BACKGROUND CHECK AGREEMENT If offered a position at the McLean County Nursing Home, I understand that for continued employment I am required to successfully pass a Criminal Background Check. I authorize the McLean County Nursing Home to perform the Criminal Background Check and agree to have a fingerprint background check as established by Illinois Department of Public Health. Signature Date