APPLICANT INFORMATIONNameFirstLastDate*Email address*Present AddressCityStatePlease selectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip CodePermanent Address (If different from above)CityStatePlease selectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip CodeCell PhoneHome PhoneBest time to reach youDate available for workPosition applying for*Other position(s) applying for:Would you like to work on a full or part time basis?Full-timePart-timeEitherAre you willing to work weekends?YesNoDesired shift1st2nd3rdAnyIf you are under the age of 16, are you able to provide a work permit?*YesNoHave you submitted an application here before?YesNoIf yes, please provide date(s):Have you worked here before?YesNoIf yes, provide date(s) and position(s) held:Are you related to anyone who currently works here?YesNoIf yes, provide name(s) and relationship(s):If it has been provided to you, are you able to perform the essential functions as stated in the role description?YesNoNeed more informationIf no, please explain:If they have been explained to you, are you able to meet the attendance requirements?YesNoNeed more informationIf no, please explain:EDUCATIONAL BACKGROUNDSchool #1City, StateYears CompletedMajor/Minor or CertificationCompletedDiplomaDegreeCertificationOtherIf other, please explain:School #2City, StateYears CompletedMajor/Minor or CertificationCompletedDiplomaDegreeCertificationOtherIf other, please explain:School #3City, StateYears CompletedMajor/Minor or CertificationCompletedDiplomaDegreeCertificationOtherIf other, please explain:EMPLOYMENT HISTORY Beginning with your most recent work experience, please provide the following information:Employer NameCity, StateLast rate of pay:Date Employed From:To:May we contact this employer?YesNoLaterPosition:SupervisorPhoneReason for leavingEmployer NameCity, StateLast rate of pay:Date Employed From:To:May we contact this employer?YesNoLaterPosition:SupervisorPhoneReason for leavingEmployer NameCity, StateLast rate of pay:Date Employed From:To:May we contact this employer?YesNoLaterPosition:SupervisorPhoneReason for leavingREFERENCES NamePhoneYear's AcquaintedRelationship to YouNamePhoneYear's AcquaintedRelationship to YouNamePhoneYear's AcquaintedRelationship to YouApplicant’s Certification and Agreement I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Sisters of Charity of the Blessed Virgin Mary to verify their accuracy and to obtain reference information on my work performance. I hereby release Sisters of Charity of the Blessed Virgin Mary from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information. I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal. I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of the Sisters of Charity of the Blessed Virgin Mary. However, I further understand that neither the policies, rules, regulations of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either I or the Employer may terminate my employment at any time with or without notice or cause. Applicant's Signature*Date*SendThis field should be left blank