Online Employment Application to Pulaski Health Care Center below:

Your Name:

Your Email:

Your application will go directly to our Employment Department.
Employment Application to Pulaski Health Care Center
The field descriptions in this background color are required
Last Name: First Name: Middle Name:
Social Security #
Address:
City State:
Zip: Phone:
Length of time at this address: Position Applying for:
Are you legally eligible for employment in the United States ?
(A U.S. citizen or alien authorized to work in the U.S.)   		Yes No
Have you ever been charged or convicted of a crime? (this includes misdemeanors & felonies Yes No
If Yes to above question,
please explain
Do you have any relatives employed by Pulaski Health Care Center ? Yes No
If Yes to above question,
please list names & relationship
Do you have any restrictions that would not allow you to perform
the essential functions of the job for which you are applying?		 Yes No
Are you on layoff and subject to recall ? Yes No
Are you at least 18 years of age ? Yes No
Have you ever been discharged, or requested to resign ? Yes No
Are you currently using or consuming illegal drugs or controlled
substance or alcoholic beverage that would impair your ability to work ?		 Yes No
Work History:
Please list chronologically, beginning with most recent employment experience.
Employer: Address/City:
Job Position Telephone #
Employed from (MM/YYYY): To: (MM/YYYY)
Salary:    Starting       Ending
Name of supervisor
Describe the work you did
Reason for Leaving:
 
Employer: Address/City:
Job Position Telephone #
Employed from (MM/YYYY): To: (MM/YYYY)
Salary:    Starting       Ending
Name of supervisor
Describe the work you did
Reason for Leaving:
 
Employer: Address/City:
Job Position Telephone #
Employed from (MM/YYYY): To: (MM/YYYY)
Salary:    Starting       Ending
Name of supervisor
Describe the work you did
Reason for Leaving:
References: - List 3 non-relatives who are familiar with your qualifications.
Name:
Occupation/Relationship
Years Known
Telephone #
Education:
High School
College
Other
Name:
Address: 		Name
Address 		Name
Address
Years Completed: Years Completed Years Completed
Course of Study: Course of Study: Course of Study:
License - Certification - Registration:
Type Lic./Cert./Reg. No State Expiration date
Type Lic./Cert./Reg. No State Expiration date
CPR Expiration Date Date of last physical exam Last TB/CXR Date
DRUG TESTING WILL BE DONE UPON EMPLOYMENT
AND AT RANDOM DURING EMPLOYMENT
Date available to begin work Salary Desired
Schedule Shift
Please read the following Statement:
I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.

I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment.

I hereby authorize persons such a schools, my current employer (if applicable) and previous employers and other organizations to provide this facility with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information.

I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the proceeding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.

I have read, understand, and agree with the above.

Checking this box is your online signature that certifies you have read and accept the above statements.
Enter date of online signing

Disclosure & Release of Information Authorization Investigation Consumer Report
As an applicant for employment or an employee, you are a consumer with rights under the Fair Credit Reporting Act. When evaluating you for employment, promotion, reassignment, or retention as an employee, an investigative consumer report may be obtained from a consumer reporting agency and may be obtained at any time during the application process or during your employment.

I authorize Pulaski Health Care Center to obtain information from all personnel, educational institutions, government agencies, companies, corporations, credit reporting agencies, law enforcement agencies at the federal, state or county level, relating to my past activities, to supply any and all information concerning my background. This information may include, but is not limited to, academic, residential, achievement, previous employment verification and/or job performance, worker's compensation, professional licenses, credit reports, driving history, and criminal history records.

I understand that an Investigative Consumer Report may be prepared summarizing this information. The report may include information obtained through personal interview regarding my character, general reputation, personal characteristics, and/or mode of living. I may also have the right to request additional disclosures regarding the nature and scope of the investigation, as well as a written summary of my rights under FCRA. If requested, the consumer reporting agency will explain the contents of my file.

I understand that by requesting this information, no promise of employment is being made. I also understand that a photocopy of this authorization be accepted with the same authority as the original: and that if employed by Pulaski Health Care Center, this authorization will remain in effect throughout such employment.

Checking this box is your online signature that certifies you have read the above statement.
Enter date of online signing

Date of Birth (for identification purposes only)

Please enter the letters on the left in the box on the right, to help stop SPAM
Watch upper and lower case
Double check you application then


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