All fields are required. Complete and submit this form on-line, or complete this Adobe Acrobat application, which may be saved to your hard drive, and then faxed (at (401) 884 - 7977), or e-mailed to Brentwood Nursing Home as an attachment Position applied for: Administration Activities Nurse-RN Nurse-LPN Certified Nursing Assistant Dietary Aide Housekeeper Porter Maintenance Laundry Cook Personal Information Last Name:  First Name:  Middle Initial:  Present Address:    City  State:   Zip: Telephone: Social Security No:  AlternateAddress:  (If different from above)   City  State:   Zip: Telephone: Shift Preference: 1st Shift 2nd Shift 3rd Shift Flexible Rate of Pay Expected: $ Would you work Full-Time: YesNo  Part-Time: YesNo Specify the days and hours if Part-time: List any volunteer or Community Service Positions (work) which you feel are related to the position for which you are applying: Briefly state any special skills or qualifications you have which you feel are related to the position for which you are applying. Were you previously employed by us: YesNo If yes, when?  List any friends or relatives working for us Name: Relationship: Name: Relationship: Have you ever been convicted of any crime? YesNo Note: Conviction of a criminal offense will not necessarily preclude your employment If yes, describe in full: If your application is considered favorably, on what date will you be available for work?  Person to be contacted in case of emergency: Name:  Relationship:  Address:    City  State:   Zip: Telephone: Record of Education School Name and Address of School Course or Major Start Year End Year Year Completed List Degree or Diploma High School 910 1112 College 12 34 Other School 12 34 Military Service Record Were you in U.S. Armed Forces?: YesNo If yes, what branch?  Dates of Duty: From:   To:   Rank at Discharge  List duties in the service including special training: Personal References Name and Occupation Address Phone Number Employment Record (List All Present and Past Positions, Beginning with Most Recent) Name and Address of Company and Type of Business Start Mo./Yr. End Mo./Yr. Describe in detail the work you did Weekly Starting Salary Weekly Ending Salary Supervisor Have you ever been bonded? YesNo If yes, on what jobs?    May we contact the employers listed above? YesNo If not, indicate which ones you do not wish us to contact: This institution does not discriminate in hiring or in 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 or 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 voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take a physical examination and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physician examination whcih relates to the essential duties I would be required to perform. I understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. 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.