PERSONAL DATA Date: Name: (last, first, middle) E-Mail Address: Current Address: Street: City/Town: State: Zip Code: Previous Address: Street: City/Town: State: Zip Code: Phone: Alternate Phone: Are you under 18 years of age? If you answered yes, state your date of birth: Yes No If hired, can you provide written evidence that you are authorized to work in the United States? Yes No Any offer of employment will be contingent upon applicant providing appropriate documentation in accordance with the Immigration Reform Act of 1986 establishing applicant's legal right to work in the United States. Person to contact in case of emergency: Name: Relationship: Address: Phone Number: REFERRAL SOURCE How did you learn of Penacook Place? (select one) Newspaper School Walk-In Employee Agency Other referral source: List any friends/relatives who work here: Have you ever been employed by Penacook Place? Yes No If yes, in what position and when? IV. EMPLOYMENT INFORMATION Position applying for: Date Available: Schedule desired (check all that apply): Full Time Part Time Permanent Temporary Number of hours/week desired: Shift desired (check all that apply): Days Evenings Nights Weekends Only Rotating Weekends If required, would you be able to work (check all that apply): Days Evenings Nights Weekends Only Rotating Weekends EMPLOYMENT HISTORY Please provide a list of all previous employers, starting with the most recent employer. Any verifiable work performed on a volunteer basis may be included. 1. Name of Employer: Starting Position: Ending Position: Employer Address: Starting Wage: Ending Wage: Name/Title of Supervisor: Phone Number: Dates of Employment: Reason for leaving: 2. Name of Employer: Starting Position: Ending Position: Employer Address: Starting Wage: Ending Wage: Name/Title of Supervisor: Phone Number: Dates of Employment: Reason for leaving: 3. Name of Employer: Starting Position: Ending Position: Employer Address: Starting Wage: Ending Wage: Name/Title of Supervisor: Phone Number: Dates of Employment: Reason for leaving: Please explain any gaps in employment: EDUCATION Please check last grade completed: Grammar School / Jr. High School / High School 1 2 3 4 College 1 2 3 4 Name and Address of High School: Did you graduate? Yes No Type of degree/diploma? Name and Address of College: Did you graduate? Yes No Type of degree/diploma? Name and Address of Other: Did you graduate? Yes No Type of degree/diploma? Other Skills: PROFESSIONAL REGISTRATIONS * LICENSES * CERTIFICATES Please identify all locations or jurisdictions where you have held such registrations, licensed or permits. Please identify all locations or jurisdictions where you have held such registrations, licenses or permits. Type (RN, LPN, C.N.A., or Other): Number: Expiration Date: State or Jurisdiction: Type (RN, LPN, C.N.A., or Other): Number: Expiration Date: State or Jurisdiction: Type (RN, LPN, C.N.A., or Other): Number: Expiration Date: State or Jurisdiction: Please select YES or NO for the following questions: 1. Do you have any limitations, suspensions, etc. against any professional registrations, licenses, certificates, or permits? Yes No 2. Have you ever been the subject of any professional licensure, registration or certification investigation, disciplinary action, or probation or similar action taken against any professional license, registration or certification held by you? Yes No 3. Has any license, registration or certification held by you been modified, limited, suspended or otherwise altered or revoked? Yes No 4. Have you ever been the subject of any investigation into an allegation of patient/resident abuse, neglect or misappropriation of property? Yes No 5. Have you been the subject of any disciplinary action during your previous employment? Yes No If you answered yes to any of these questions, please explain: Please review your answers and submit your preliminary application info to the Human Resources office. We will contact you to complete the application process. Penacook Place does not discriminate on the basis of race, color, national origin, handicap, age, sex, creed or marital status in admission or access to or treatment or employment in its programs and activities.
Name: (last, first, middle)
E-Mail Address:
Current Address:
Street:
City/Town:
State:
Zip Code:
Phone:
Alternate Phone:
Relationship:
How did you learn of Penacook Place? (select one)
Newspaper School Walk-In Employee Agency
Other referral source:
List any friends/relatives who work here:
Shift desired (check all that apply): Days Evenings Nights Weekends Only Rotating Weekends
1. Name of Employer:
Starting Position:
Ending Position:
Employer Address:
Starting Wage:
Ending Wage:
2. Name of Employer:
3. Name of Employer:
Please identify all locations or jurisdictions where you have held such registrations, licensed or permits.
Type (RN, LPN, C.N.A., or Other):
State or Jurisdiction:
Please review your answers and submit your preliminary application info to the Human Resources office. We will contact you to complete the application process.
Penacook Place does not discriminate on the basis of race, color, national origin, handicap, age, sex, creed or marital status in admission or access to or treatment or employment in its programs and activities.
Penacook Place • 150 Water Street • Haverhill, MA 01830 • 978-374-0707 • info@penacookplace.org
Penacook Place • 150 Water Street • Haverhill, MA 01830 • 978-374-0707 • info@penacookplace.org