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Application for Employment

You can optionally download and print out this application to mail in.

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.

Position(s) Applied For:
How Did You Learn About Us?:	Advertisement Friend Relative (specify) Employee (specify) Other (specify)
Name:
Address:
Cell Phone:
Home Phone:
Fax:
E-mail:
If you are under 18 years of age, can you provide required proof of your eligibility to work?	Yes No
Have you ever filed an application with us before?	Yes No If yes, give date:
Have you ever been employed with us before?	Yes NoIf yes, give date:
Are any of your relatives working here?	Yes No If yes, give name:
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment	Yes No
Do you prefer to work:	Full Time Part Time Weekends PRN What Shift?
Have you been convicted of a felony within the last 7 years?	Yes NoIf yes, please explain:

Education

	Elementary School	High School	Undergraduate College / University	Graduate / Professional
School name and Location
Years Completed
Diploma/Degree

Professional Licenses:

Type:

Number:

Are you a state tested nursing assistant?:

Yes

If yes:
Issue Date:
If no:
Completed training program:
Test date:

Summarize special job-related skills and qualifications acquired from employment or other experience:

Employment Experience

Start with your current or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap or other protected status.

Employer 1

Dates Employed:
Hourly Rate/Salary:
Work Performed:
Employer:
Address:
Phone:
Job Title:
Supervisor:
Reason for Leaving:

Employer 2

Dates Employed:
Hourly Rate/Salary:
Work Performed:
Employer:
Address:
Phone:
Job Title:
Supervisor:
Reason for Leaving:

Employer 3

Dates Employed:
Hourly Rate/Salary:
Work Performed:
Employer:
Address:
Phone:
Job Title:
Supervisor:
Reason for Leaving:

Employer 4

Dates Employed:
Hourly Rate/Salary:
Work Performed:
Employer:
Address:
Phone:
Job Title:
Supervisor:
Reason for Leaving:

Applicant’s Statement

I understand that all information furnished by me is certified to be true. All information is subject to verification. I understand that any misrepresentation or falsification of information requested herein will be cause for rejection of this application or for subsequent discipline up to and including dismissal from employment. I understand I may be required to submit to a pre-employment/post offer physical examination to determine my physical ability to perform my job.

I further understand that my employment or continuation thereof is contingent upon the results of a drug screening analysis for substance abuse. The results of such analysis may be grounds for disqualifying me or terminating my employment.

I authorize Montefiore to verify any information concerning my previous employment (except as indicated above), education, medical history, or criminal record, with appropriate individuals, companies, institutions, or agencies, and I authorize them to release such information as Montefiore requires, including medical records, school records, employment records, and criminal records, without any obligation to give me written notice of such disclosure.

I further understand that, subject to any labor agreement, my employment is not guaranteed for any term, and that my employment may be terminated by Montefiore or myself for any reason at any time in accordance with Terms and Conditions of Collective Bargaining Agreement. I further understand that as a non union employee the at-will nature of my employment may only be altered in writing, signed and approved by the CEO of Montefiore. Finally, I agree that my employment is conditional until such time as the results of my pre-employment physical and drug test are known.

By submitting this online form, I hereby agree to these terms.

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Application for Employment

Education

Employment Experience

Employer 1

Employer 2

Employer 3

Employer 4

Applicant’s Statement

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