PERSONAL INFORMATION Have you worked at Salem before? If so, when:
SALEM HOME POSITION Shift(s) I am able to work...
Choose one: How did you learn about SALEM HOME?
Are your currently employed? Are you related to anyone at SALEM HOME? If so, please give name(s) & relation...
Have you ever been convicted of a crime? If so, please explain...
EDUCATION Choose the education level(s) you have completed
HIGH SCHOOL
COLLEGE / UNIVERSITY
TRADE SCHOOL / SPECIALIZED EDUCATION
Please explain your areas of highest proficiency, special skills or other items that may contribute to your abilities in performing the above mentioned position.
PREVIOUS WORK EXPERIENCE This would be my First Job
COMPANY / BUSINESS #1 (Most Recent) Company #1... Job notes, tasks performed, & reason for leaving
COMPANY / BUSINESS #2 Company #2... Job notes, tasks performed, & reason for leaving
COMPANY / BUSINESS #3 Company #3... Job notes, tasks performed, & reason for leaving
REFERENCES Give three references who are NOT relatives or a previous employer
REFERENCE #1
REFERENCE #2
REFERENCE #3
FINAL STEPS If you are applying for an RN, LPN, CMA, CNA or other position requiring a license or registration number, please complete the following.
License Expiration Date... Provide here any statements of added information that you feel would better your application or make us more aware of your abilities, desires or circumstances...
TERMS & CONDITIONS... I certify that I have read and understand the applicant note on this form and that the answers given by me to the forgoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize Salem Home 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.
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Salem Home is a drug-free workplace. Applicants who have been offered a position with Salem Home must submit to a drug screen and criminal history background check prior to their first day on the job. All expenses incurred in the drug testing and background check will be the responsibility of Salem Home.
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Your employment with Salem Home is voluntarily entered into and you are free to resign at any time. Similarly, Salem home is free to conclude an employment relationship where it believes it is in the corporation’s best interest at any time. While we hope our relationship will be long and mutually beneficial, it should be recognized that neither you, nor Salem Home, have entered into any contract of employment, express or implied. Our relationship is and will always be one of voluntary employment.
I agree to the terms & conditions
SUBMIT APPLICATION
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