Employment Application
 
 
 
APPLICATION FOR EMPLOYMENT

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability or national origin. Consistent with the Americans with Disabilities Act, applicants may request accommodations needed to participate in the application process.

 

Personal Information
Last Name:
First Name: Middle Name:
Date: / /
Email Address:
SSN:
Are you 18 years of age or older? Yes No


Address

Present Address:
City:
State:
Permanent Address:
City:
State:
Phone (Home):
Phone (Work):
Referred By:


Employment Desired

Position:
Date you can start:
Salary desired:
Are you now employed? Yes No
if so, may we inquire of your present employer? Yes No
Have you ever applied to this company before? Yes No When? Where?


Education
High School
Name:
Location:
Choose last year you completed : 1 2 3 4
Did you graduate?
College
Name:
Location:
Choose last year you completed : 1 2 3 4
Did you graduate?
Subjects studied and degree(s) received?
Graduate School
Name:
Location:
Choose last year you completed : 1 2 3 4
Did you graduate?
Subjects studied and degree(s) received?


General

Subjects of special study or research work:
Job related skills (typing, driver's license, etc.):


Employment History
Employment 1
Date (Month & Year): From to
Name of Employer:
Address of Employer:
Phone Number:
Salary (upon leaving):
Position:
Reason for Leaving:
Employment 2
Date (Month & Year): From to
Name of Employer:
Address of Employer:
Phone Number:
Salary (upon leaving):
Position:
Reason for Leaving:
Employment 3
Date (Month & Year): From to
Name of Employer:
Address of Employer:
Phone Number:
Salary (upon leaving):
Position:
Reason for Leaving:
Employment 4
Date (Month & Year): From to
Name of Employer:
Address of Employer:
Phone Number:
Salary (upon leaving):
Position:
Reason for Leaving:


References

(List below three persons not related to you, whom you have known at least one year)
Reference 1
Name:
Address:
Phone Number:
Position:
Years Acquainted:
Reference 2
Name:
Address:
Phone Number:
Position:
Years Acquainted:
Reference 3
Name:
Address:
Phone Number:
Position:
Years Acquainted:
Have you ever been convicted of any violation of the law other than minor traffic violations?
Yes No
(If yes, give date(s) and location of conviction, charge(s), and disposition.)

 

Under Maryland Law, an employer may not require or demand any applicant for employment or prospective employment or any employee to submit to or take a polygraph, lie detector or similar test or examination as a condition of employment or continued employment. Any employer who violates this provision is guilty of a misdemeanor and subject to a fine not to exceed $100. Potomac Valley Nursing & Wellness Center will abide by this law and will not require this as a condition of employment or continued employment.

 
Print Name:

 

If you are to be hired by the Company, you will be required to attest to your identity and employment eligibility, and to present documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements. You may fill out the application online, download a copy and fax to 301-762-3216, or mail or deliver one to the facility.