Employment Application

Previous Employment

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

YES NO

Why do you want to work for Nightingale?

Education

High School:

Address:

From:

To:

Did you graduate?

YES NO

Diploma:

College:

Address:

From:

To:

Did you graduate?

YES NO

Degree:

Other:

Address:

From:

To:

Did you graduate?

YES NO

Degree:

Skills and Qualifications

Have you had any other experiences or qualifications in addition to those indicated which relate to the job for which you are applying? (Include any foreign language knowledge) If so please describe:

Additional Employment Related Information

List any relatives or friends working for this company - Name:

Position:

Relationship:

Were you referred by an employee of Nightingale?

Yes No

Name of Employee that referred you:

If hired, would you have a reliable means of transportation to and from work?

Yes No

Do you have reliable internet at home?

Yes No

Internet Provider:

Are you at least 18 years old?

Yes No

If hired, can you present evidence of your U.S citizenship or proof of your legal right to live and work in this country?

Yes No

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodations?

Yes No

If accommodations are needed, please describe:

References

Please list three professional references.

Reference 1

Full Name:

Relationship:

Company:

Phone:

Address:

List Previous Addresses During the Last Five Years

Street Address:

City:

State:

Zip:

From:

To:

Street Address:

City:

State:

Zip:

From:

To:

Street Address:

City:

State:

Zip:

From:

To:

Street Address:

City:

State:

Zip:

From:

To:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature:

Date:

Employment Application

Applicant Information

Professional or Technical Information: (Check one)

Nearest Relative not living with you:

Previous Employment

Education

Skills and Qualifications

Additional Employment Related Information

References

Reference 1

Military Service

List Previous Addresses During the Last Five Years

Disclaimer and Signature

Applicant Information

Professional or Technical Information: (Check one)

Nearest Relative not living with you:

Previous Employment

Education

Skills and Qualifications

Additional Employment Related Information

References

Reference 1

Military Service

List Previous Addresses During the Last Five Years

Disclaimer and Signature

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