Personal Information Present Street Address
Select a state * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Are You 18 Years or older? * Yes No
If you are hired, you may be required to submit proof of age.
Job Information Current Open Positions(s) for Which You Are Applying
Choose a position * CNA/RA Days (PRN) LPN
Choose a position CNA/RA Days (PRN) LPN
Choose a position CNA/RA Days (PRN) LPN
Are you related to any AMMC employees? Yes No
Have you ever used another name? Yes No
Have you worked at AMMC, Chateau on the Ridge or for AMMC Physician Services before? Yes No
Can you work full-time? Yes No
Can you work part-time? Yes No
Are you legally authorized to work in the U.S.? Yes No
If hired, can you furnish proof you are eligible to work in the U.S.? Yes No
Have you ever been convicted of or pleaded guilty to any law violation (except for speeding or parking violations)? * Yes No
Educational History High School Last Year Attended in School 9 10 11 12
Degree or Certificate Graduated/GED? Yes No
College Last Year Attended in School 1 2 3 4
Degree or Certificate Graduated/GED? Yes No
College Last Year Attended in School 1 2 3 4
Degree or Certificate Graduated/GED? Yes No
Graduate School Last Year Attended in School 1 2 3 4
Degree or Certificate Graduated/GED? Yes No
Other Degree or Certificate Graduated/GED? Yes No
Other Degree or Certificate Graduated/GED? Yes No
List any professional licenses, registration or certification you possess: (include Drivers License, if applicable)
Employment History Previous Save and continue Professional References (Other than Relatives or former Employers) Give three references who have good knowledge of your work.
State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Have you been fired from a job or asked to resign? * Yes No
Upload Resume (Only pdf, doc, docx files are allowed)
By entering my full name I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize and agree to cooperate in a thorough investigation of all statements made herein and other matters related to my background and qualifications. I understand that any investigation conducted may include a request for employment and educational history, credit reports, consumer reports, investigative consumer reports, driving record, and criminal history. I authorize any person, school, current and former employer, consumer reporting agency, and any other organization or agency to provide information relevant to such investigation and I hereby release all persons and corporations requesting or supplying information pursuant to such investigation from all liability or responsibility to me for doing so, I understand that I have the right to make a written request within a reasonable period of time for complete disclosure of the nature and scope of any investigation. I understand I am required to successfully pass a drug-screening examination. I hereby consent to a pre-and/or post-employment drug screen as a condition of being hired or of my continued employment, if required.
I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINTE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE.
Applicant Certification Please type your full name. By doing so and submitting this form you attest that you have read, understand, and are agreeing to the terms and conditions stated above.
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