Employment Application
Please complete all areas.
First Name
Last Name
Email
Phone Number
What position are you applying for?
LPN/RN
CNA
Dietary
Housekeeping/Laundry
Other
What is your desired shift?
1st
2nd
3rd
Full-Time
Part-Time
Are you Covid vaccinated? & Have you had a flu vaccine this year?
Yes, I am Covid Vaccinated
No, I am not Covid Vaccinated
Yes, I have had a flu vaccine this year.
No, I have not had the flu vaccine this year.
Has any professional license that you hold ever been suspended or revoked?
Yes
No
Date you can start:
Have you ever applied or worked for CNC before, and if so when?
Have you ever been convicted of or plead guilty to a crime other than a minor traffic violation? If yes, please explain.
Have you ever been disciplined for resident or child abuse? If so, explain:
Tell us about any license you hold, what organization or state it was issued in and your license number:
Please list all schools you have attended, your graduation date, & the type of diploma or license obtained:
Employment History: Include company name, dates of employment, position held & reason for leaving:
Include 3 References, relationship, years known, & phone number:
I certify that all statements made in this application are, to the best of my knowledge, correct. Should any of the statements be subsequently proved incorrect, I understand the employer may cancel my employment.
I hereby give permission for you to contact my previous employers, schools & references listed.
I understand that any employment by this facility will be on a 90 day introduction period, & agree to abide by CNC rules & regulations.
Your Signature
*
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If you have a resume, please upload here:
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