Come work with us at North Shore

First name

Middle Name (or Initial)

Last name

Phone

Address

Where did you hear about us?

If you cannot be reached at the above number, where can we contact you (phone # and name of contact person)

• • Employment • •

For what position are you applying?

Start Date

Which category would you prefer?

Full Time

Part Time

PRN

Temporary

Check this box if you have worked for North Shore in the past.

If you have worked for us before, when?

Do you have relatives working at the facility for which you are applying?

Yes

• • Education • •

What is your highest grade completed?

High School Name • City/State/Country • Did You Graduate (yes/no)?

College Name • City/State/Country • Did You Graduate (yes/no)? • Degree

Other Schooling • City/State/Country • Did You Graduate (yes/no)? • Degree

Professional Licesnses and/or Certifications

Professional organization membership, honors received, volunteer or community service, special training/skills, or other qualifications you have which you feel are related to the position for which you are applying:

• • Job Related Skills • •

Can you perform the essential functions of the position for which you are applying?

Yes

Do you have a valid driver's license? (answer only if the job requires one)

Yes

Driver's License Number • Type • State of Issue

What languages are you fluent in?

• • Military Service • •

Military Branch & Country

Entry Rank

Separation Rank

Separation Date

Occupational Specialty

• • Security • •

Have you ever been convicted of an offense or otherwise been found under applicable local, State or Federal law to have committed an offense that would preclude employment in a nursing facility?

Yes

Have you ever been excluded from participation in any State or Federal health care program, including Medicaid and Medicare?

Yes

Have you ever been listed in ay of the following databases: OIG, GSA and/or OFAC? (If so, please list all that apply)

Yes

Have you ever used any names other than those listed previously in this application? (If so, please list them)

Yes

Have you ever been convicted of any law violation? (Excluding minor traffic violations) Then detail them in the next fields.

Yes

Conviction/Incident Date • City/State • Charge(s) • Plea

• • Employment History • •

Please list current (or most recent) employer FIRST; include others in REVERSE chronological order as part of your attached resume file:

Company/Employer Name

Started Employment

Ended Employment (or today's date)

Employer's Address

Employer's Phone

Supervisor's Name & Title

Job Title + Description & Responsibilities

Reason for leaving:

May we contact them?

Yes

• • Personal References • •

List THREE references/supervisors/co-workers/associates (non relatives) who are familiar with your work and abilities:

Resume File upload

Link to CV/LinkedIn

I certify that the answers given by me to the foregoing questions and statements made by me are complete and true to the best of my knowledge and belief. I understand that any false or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment.

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam

era veteran status, or on the basis of age or physical/mental disability unrelated to ability to perform the work required. No question on this

application is intended to secure information to be used for such discrimination.

I AUTHORIZE THE COMPANY AND/OR ITS AGENTS, INCLUDING CONSUMER REPORTING BUREAUS, TO VERIFY ANY OF THIS

INFORMATION INCLUDING, BUT NOT LIMITED TO, CRIMINAL HISTORY AND MOTOR VEHICLE DRIVING RECORDS. I AUTHORIZE ALL PERSONS, SCHOOLS, COMPANIES, AND LAW ENFORCEMENT AUTHORITIES TO RELEASE ANY INFORMATION CONCERNING MY BACKGROUND AND HEREBY RELEASE ANY SAID PERSONS, SCHOOLS, COMPANIES, AND LAW ENFORCEMENT AUTHORITIES FROM ANY LIABILITY FOR ANY DAMAGE WHATSOEVER FOR ISSUING THIS INFORMATION.

After an offer of employment, and prior to reporting to work, I agree to submit to a medical review. Depending on company policy and the needs of the job, I understand I may be required to be examined by a medical professional designated by the company. If company policy requires, I am

willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I have read and understood employment policies

and procedures. If employed, I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory

evidence of identity and eligibility for employment.

I UNDERSTAND THAT MY EMPLOYMENT IS AT WILL, AND THAT EITHER I OR THE FACILITY ARE FREE TO TERMINATE THE

EMPLOYMENT RELATIONSHIP AT ANY TIME WITH OR WITHOUT REASON OR PRIOR NOTICE. I ALSO UNDERSTAND THAT THE

FACILITY RESERVES THE RIGHT TO TERMINATE ME IN ITS SOLE DISCRETION, AT ANY TIME, WITHOUT PROCEDURE, CAUSE

OR PRIOR NOTICE. I UNDERSTAND THAT NO AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME, OR ANY

AGREEMENT CONTRARY TO THE FOREGOING, CAN BE MADE BY ANY COMPANY REPRESENTATIVE, OTHER THAN ITS

PRESIDENT, AND THEN ONLY IN WRITING AND SIGNED BY THE PRESIDENT.

Signature

Employment Application