Application Form

 

Please complete the form below

Name *
Name
Type of Employment
EDUCATION
Did you graduate
Did you graduate?
GENERAL INFORMATION
Are you currently employed?
Are you currently over 18 years of age?
If employment is offered, can you provide documentation that you are legally authorized to work in the USA?
If you are applying for a position involving evening or weekend work, can you fulfill such scheduling requirements?
Are you willing to work on call?
Have you ever applied for a position with us?
How were you referred to us?
To be completed ONLY if you are applying for one of the following positions: Nurses, Nurse Aides, Administrators, Assistant Administrators, Medical Directors, DNS's, ANDS's.
Have you ever been convicted of any of the following? A felony Cruelty to persons under CGS 53-20 Assault of a victim 60 years or older under CGS 53e-61; or Has been subject to any decision imposing disciplinary action by the licensing agency in any state or foreign jurisdiction.
EMPLOYMENT HISTORY
PERSONAL REFERENCES
Terms and Discolsures
This institution does not discriminate in hiring or any other decision on the basis of race, color, creed, religion, sex, sexual orientation, citizenship, nation origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability. No question on this application is intended to secure information to be used for such discrimination. I hereby affirm that the information provided in this application (and accompanying resume, if any) is true and complete to the best of my knowledge and that there is no requested information which I have omitted or have failed to include. I also agree that if I provide any false information or intentionally left out requested information, the employer may disqualify me for consideration for employment, and if employed, may result in immediate discharge. I authorize a thorough investigation, and agree to cooperate in such investigation, of my past employment and activities. I agree to release from all liabilities and responsibilities, all persons, companies and corporations requesting or supplying information. I authorize any person, school, employer or organization to provide information and opinion and release the Company and all such sources from any liability arising from the solicitation or the use of the information. I understand that this employment application and any other documents of the Company are not contracts of employment. I understand that if employed, my employment is for no definite period of time and that I may terminate my employment relationship with the Company at any time, for any reason, and the Company has the same right. I also understand that no employee or agent of the Company has the authority to offer or enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing. If employment is obtained under this application I will comply with all rules and regulations of the Company. I agree to be responsible for Company property and equipment issued to me by the Company until returned to the Company. I understand that an offer of employment is contingent on passing a physical examination which relates to the essential duties I would be required to perform. I hereby agree to submit to any lawful drug, alcohol, or other testing which may be required as a condition of employment or continued employment and understand that refusal to submit to such testing during the course of my employment may result in disciplinary action, up to and including termination.
Location(s) *
Where would like to apply?