Employment ApplicationEmployment Application Employment Application Position(s) Applied * Date * First Name * Middle Initial Last Name * Phone Number Cell Number Address * Address Line 2 City * State / Province / Region * ZIP / Postal Code * Country * Have you been employed here before? * Yes No Dates * Emergency Phone Number Email Address Can you provide proof you are eligible to work in US if offered employment? * Yes No Availability to work: Full-Time Part-Time Full-Time Part-Time Shifts: Any PM Shift Night Shift Day Shift Do any of your friends work here? * Yes No Names Do any of your relatives work here? * Yes No Names Are you subject to recall? * Yes No Company/Military Service If your application is considered favorably, on what date are you available for work? Have you ever been convicted of abuse of persons in your care? * Yes No If yes, which state(s) If yes, explain: License/Certification # Have you ever been convicted of a felony? * Yes No If yes, explain: Personal References First Name Middle Initial Last Name Relationship Phone Number How long have you known this person? First Name Middle Initial Last Name Relationship Phone Number How long have you known this person? First Name Middle Initial Last Name Relationship Phone Number How long have you known this person? Employment History Starting with present or last job, list all jobs held including military service assignments. Most Recent/Current Employer Employer Name Phone Number Address Address Line 2 City State / Province / Region ZIP / Postal Code Country Job Title Supervisor's Name Dates of Employment From To From To Reason for Leaving Second Most Recent Employer Name Phone Number Address Address Line 2 City State / Province / Region ZIP / Postal Code Country Job Title Supervisor's Name Dates of Employment From To From To Reason for Leaving Third Most Recent Employer Name Phone Number Address Address Line 2 City State / Province / Region ZIP / Postal Code Country Job Title Supervisor's Name Dates of Employment Text From To From To Reason for Leaving List special skills and qualifications acquired from employment and other experiences Education Completion of this part of the form is voluntary. All information provided will remain confidential and will not affect your application or potential for employment. We are required by law to collect this information for equal opportunity employment purposes. If skipping, scroll to the bottom to submit employment application. Race/Ethnicity (Please select one option with which you most identify) Hispanic or Latino White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Pacific Islander Two or more Gender Female Male Release Having made an application for employment with St. Luke's Home and desiring them to be informed as to my previous record and character, I hereby authorize St. Luke's Home to investigate my past record and ascertain any and all information which may concern my record and character, whether having the same record or not and release my present and past employers, references and all persons whomsoever from any damage because of furnishing said information. I certify that the answers given on this form are true and complete to the best of my knowledge. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. Applications are considered active for 90 days. This application is retained for one year after submission. Signature Today's Date TOBACCO FREE FACILITY Our tobacco-free policy is established to do:Protect the health and safety of all Employees and Visitors to the Workplace Property.Reduce the exposure of Employees and Visitors to smoking, secondhand smoke and the use of other Tobacco Products.Establish a standard of healthy, tobacco-free behavior.Encourage employees who currently use tobacco products to utilize available cessation. Captcha Submit If you are human, leave this field blank.