Woodstock Vermont Nursing Care Facility - Mertens House Vermont Long Term Nursing Care


APPLICATION FOR EMPLOYMENT

Mertens House is an equal opportunity employer and does not discriminate against applicants or employees on basis of sex, race, color, religion, national origin, ancestry, genetic information, HIV positive blood test results, sexual orientation, gender identity, health coverage status, age or any other legally protected status, nor does it discriminate against qualified individuals with disabilities.
Name: 
Address 1: 
Address 2: 
City: 
State: 
Zip: 
Home Phone: 
Work Phone: 
Cell Phone: 
E-mail: 

Position applied for
Date available to start work
Are you over 18 years of age?   Yes   No
Have you applied to work with us before?   Yes   No
If yes, when?


Are you willing to work an irregular schedule, weekends, overtime, and on different shifts when necessary?   Yes   No
If no, please explain

How did you hear about us?

Education

High School
Name and address
Years completed
Graduate / Major
College
Name and address
Years completed
Graduate / Major
Other
Name and address
Years completed
Graduate / Major


Employment History
(Most recent employment first)

Dates of employment
Employer Name & Address
Position Held
Salary/Wage
Reason for leaving



Dates of employment
Employer Name & Address
Position Held
Salary/Wage
Reason for leaving



Dates of employment
Employer Name & Address
Position Held
Salary/Wage
Reason for leaving



Dates of employment
Employer Name & Address
Position Held
Salary/Wage
Reason for leaving



Dates of employment
Employer Name & Address
Position Held
Salary/Wage
Reason for leaving


Personal References

Name: 
Address: 
Phone: 
E-mail: 

Name: 
Address: 
Phone: 
E-mail: 

Name: 
Address: 
Phone: 
E-mail: 



U.S. Military Service
Branch
Date of Service
Rank
Duties


Other experience or qualifications

Have you been convicted of a felony within the last ten years?   Yes   No
If yes, please explain

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?   Yes   No


In case of emergency notify:
Relationship
Telephone Number:


Certification and Authorization
Please read thoughtfully

I certify that all facts I have stated in this Employment Application are true and complete and I acknowledge that Mertens House is relying on the accuracy of the information provided in making a hiring determination. I authorize Mertens House to verify the accuracy of the information provided herein, and I authorize former employers, educational institutions and credit agencies to release information concerning me to Mertens House. I also authorize Mertens House to give references and provide information about me in response to inquiries subsequent to my employment if I am hired. I understand that falsification, misrepresentation or omission of requested facts may result in denial of employment or, if I am employed by Mertens House, may result in immediate dismissal. I understand and agree that if I am hired, my employment will be for no definite period and may, regardless of the date of payment of wages, be terminated at any time without notice and with or without reason, by me or by Mertens House. I also understand and agree that no one has authority to promise me job security or continued employment except the Administrator at Mertens House in a formal written agreement signed by both of us.

I have read and agree to the conditions above.

Agree   Disagree



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