Social Security No.*
If not a U.S. citizen, do you have the legal right to remain permanently and work in the United States?
Alien Reg. No.
Position(s) applied for:*
Which shift are you willing or able to work? (Put 1, 2, and 3 in order of preference)*
How many hours would you prefer to work in a week?
Are you willing to work weekends and holidays?
Check the days you can work:
Date you can start*
Have you ever worked for this company before?
If yes, when?
Are you currently attending school/college?
Highest grade completed
Name of last school attended
List of training beyond high school
List area of Study and Degree
Certified nurse aide/orderly in Illinois?
Other licenses or certificates
List below your work experience starting with your present or last place of employment:
Employer's Name & Address
Reason for leaving
List three persons not related to you:
Do you agree to the applicant's statement at the bottom of this page?
I would like to tour:
---Retirement community (independent living in our cottages and apartments) – Julie BeltrameaHealth Center (skilled nursing care and rehabilitation) – Kara PaulyAssisted Living – Angie Pate
Inquiring For: SelfParentSpouse
Have you ever done volunteer work?---YesNo
What Kind Of Voluteering?
How much time do you wish to volunteer? DailyWeeklyMonthlyAnnuallyAs Needed
Days of the week you prefer: SundayMondayTuesdayWedesdayThursdayFridaySaturday
Preferred Time: MorningAfternoonEvening
Please check any of the following areas in which you would be interested in volunteering.
Direct Interaction with Residents:Visit with residentsRead (book, mail, magazine, newspaper, Bible)Assist with daily ActivitiesCraft DemonstrationPlay Games (Cards, Puzzles, etc.)Help with BingoWheel chair walks inside/outsideHelp on Alzheimer’s UnitAssist Residents to/from Beauty ShopWrite LettersRead DevotionalsMonthly PotluckHelp with special outingsTransportationManicuresHelp in Dining RoomLead ExercisesTransport to Activities
Indirect Volunteer Work:Lead Prayer-Noon MealFold LaundryWindow WashingMaintenance WorkAnswer PhonesNewsletter AssemblyOffice WorkGolf OutingAuctionSpring PlantingCook/Grill Special OccasionsBlood DriveOutdoors WorkGarden workAssemble MailingsHelp with groceriesGreeters Desk
Minimal or Indirect Resident Interaction:Play piano or keyboardPlay an instrumentSing-A-LongDeliver MailDeliver NewspapersNewsletter DeliveryHost Birthday PartyHelp with parties (Holiday, Birthday, etc.)Help put up seasonal decorations
At Your Home:Sew/MendQuiltBakeType