Personal Information

Full Name

Email Address

Phone Number

Address

City

State

Zip

Social Security Number (SSN)

Employment Information

Are you legally eligible to work in the United States?
YesNo

Have you ever been employed by Sevya Homes Assisted Living Facility before?
YesNo

Certifications and Licenses

Do you hold any of the following certifications?

Certified Nursing Assistant (CNA)
YesNo

Geriatric Nursing Assistant (GNA)
YesNo

Medication Technician
YesNo

CPR/First Aid
YesNo

Health Screening

MMRV Vaccination (Measles, Mumps, Rubella, Varicella)
CompletedNot Completed

TB Clearance
CompletedNot Completed

COVID-19 Vaccination
CompletedNot Completed

Education

1. High School

High School Name

Location

Did you graduate?
YesNo

Degree/Diploma

2. College/University

College/University Name

Location

Did you graduate?
YesNo

Degree

3. Other (Trade, Vocational, etc.)

School Name

Location

Did you graduate?
YesNo

Degree/Certification

Work Experience

1. Most Recent Employer

Employer

Position

Dates Employed

Reason for Leaving

2. Previous Employer

Employer

Position

Dates Employed

Reason for Leaving

3. Previous Employer

Employer

Position

Dates Employed

Reason for Leaving

References (Optional)

2. Reference

Name

Relationship

Phone Number

Email Address

3. Reference

Name

Relationship

Phone Number

Email Address

Background Check and Disclaimer

Have you ever been convicted of a felony or misdemeanor?
YesNo

If yes, please explain:
Explanation

Conviction will not necessarily disqualify an applicant from employment. The nature of the offense and its relevance to the position applied for will be considered.

Agreement

By signing below, I certify that all information provided is true and complete to the best of my knowledge. I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time.

Signature (type your name)

Name Printed

Date

Attachments

Please attach copies of the following documents:

Government-issued IDPassportWork AuthorizationSocial Security CardResumeCertification(s) and License(s)Degree/CertificatesHealth Screening Reports (MMRV Vaccination, TB Clearance, COVID Vaccination)

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