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CertifiedNursingAssistant

Si no entiende preguntas por favor pregunte y se pueden conseguir alguien que le tradusca.

Contact Information

First Name(Required)

Middle Name

Last Name(Required)

Address(Required)

Street Address Address Line 2 City State Zip Code

Phone Number(Required)

Email(Required)

Date Available(Required)

General Information

If you are under 18 years of age, after employment can you submit a work permit?(Required)

Yes

Are you on layoff or subject to recall?(Required)

Yes

Have you applied here before?(Required)

Yes

When(Required)

Have you previously been employed here?(Required)

Yes

When?(Required)

Under what name?(Required)

If employed, may we inquire of your present employer?

Yes

Not applicable

Have you ever been convicted of a criminal offense?(Required)

Yes

State the nature of the crime(s), when and where convicted, and disposition of the case:(Required)

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

Yes

If no, describe the function that cannot be performed.(Required)

(Note: We comply with the American with Disabilities Act and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.)

If employed, can you submit verification of your right to work in the United States?(Required)

Yes

Scheduling & Availability

Please list any days/shifts for which you are NOT available to work:

Are you available to work:

Holidays

Rotating Shifts

Overtime

Flexible Schedule

Any other scheduling consideration?

Education and U.S. Military Service

Trade/Business school Name

Location

Years Completed/Degree

College Name

Location

Years Completed/Degree

Post Graduate School Name

Location

Years Completed/Degree

Additional school history

If you need more room for your school history, please submit a PDF or word document. Accepted file types are pdf, doc and docx.

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 128 MB, Max. files: 1.

Certificates & Licenses

List certificates/licenses you hold or specialized training you've completed that may help you qualify for employment. Please include the license number and expiration date:

Name of License

License Number

Exp. Date

Name of License

License Number

Exp. Date

Name of License

License Number

Exp. Date

Additional License History

If you need more room for your license history, please submit a PDF or word document. Accepted file types are pdf, doc and docx.

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 128 MB, Max. files: 1.

Employment History

Please upload a resume and cover letter or fill out your job history using the form below. If you use the form for your job history, please list your history starting with your most recent. If you need more history entries, you may upload a document after your history has been filled out.

Would you like to:(Required)

Upload Resume and Cover Letter

Fill out Job History

Upload Cover Letter

Please upload cover letter. Allowed file types are PDF, doc and docx

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 128 MB, Max. files: 1.

Upload Resume(Required)

Please upload resume. Allowed file types are PDF, doc and docx

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 128 MB, Max. files: 1.

Employer

Supervisor Name

Supervisor First Name Supervisor Last Name

Supervisor Title

Phone Number

Employee Title

Employer Address

Street Address Address Line 2 City State Zip Code

Start Date

End Date

Job Duties

Reason for leaving

Employer

Supervisor Name

Supervisor First Name Supervisor Last Name

Supervisor Title

Phone Number

Employee Title

Employer Address

Street Address Address Line 2 City State Zip Code

Start Date

End Date

Job Duties

Reason for leaving

Employer

Supervisor Name

Supervisor First Name Supervisor Last Name

Supervisor Title

Phone Number

Employee Title

Employer Address

Street Address Address Line 2 City State Zip Code

Start Date

End Date

Job Duties

Reason for leaving

Additional Job History

If you need more room for your job history, please submit a PDF or word document. Accepted file types are pdf, doc and docx.

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 128 MB, Max. files: 1.

Acknowledgement

Please read carefully and initial below each paragraph and type your name at the end of the form to sign electronically.

Withholding Information(Required)

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and complete to the best of my knowledge. I further certify that I, the undersigned, have personally completed this application. I understand that my omission or statement of facts on this application, on any document used to secure employment, on any health examination or form, or in any interview(s) may be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovered.
Type your initials to agree to these conditions

Proprietary Information(Required)

Except as required in the performance of my duties, I understand and agree that I will not at any time during or after my employment use, disclose or disseminate any confidential information or any other information of a secret propriety, or generally undisclosed nature relating to Hollenbeck Palms, or its residents, employees, plans or procedures. I agree to deliver to Hollenbeck Palms any and all copies of confidential information, or other Hollenbeck's property, upon termination of the employment relationship or at any time upon my employer's request. I also agree not to solicit employees of Hollenbeck Palms either during or for one year after employment to leave Hollenbeck and commence work with another employer.
Type your initials to agree to these conditions

Authorization(Required)

I authorize Hollenbeck Palms to investigate all statements in this application as well as any other records concerning me and I will release all persons whomsoever from any claims, demands, or liabilities on account of furnishing such information, and Hollenbeck Palms may without liability, truthfully disclose said information and answer all inquiries and references concerning me.
Type your initials to agree to these conditions

Consent to Testing(Required)

I understand that any offer of employment is conditional upon satisfactorily passing any and all tests or verifications including, but not limited to: fingerprint check, medical exam and drug/alcohol test.
Type your initials to agree to these conditions

Consent to Rules and Regulations(Required)

I understand that I am required to abide by all rules and regulations of Hollenbeck Palms
Type your initials to agree to these conditions

Electronic Signature(Required)

By typing your name, you agree to all the above conditions

Date Submitted(Required)

Please type date submitted

Phone

This field is for validation purposes and should be left unchanged.

Hollenbeck Palms

General
(323) 263-6195

Admissions/Sales
(323) 307-4505

573 South Boyle Avenue
Los Angeles, CA 90033

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