Apply Online

Name*

Street Address*

City*

State*

ZIP*

Home Phone*

Cell Phone*

Email*

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.

Employment Desired

Position(s) applied for:*

Wages expected:*

Which shift are you willing or able to work? (Put 1, 2, and 3 in order of preference)*

First

Second

Third

How many hours would you prefer to work in a week?

Minimum hours:*

Maximum hours:*

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

Grade School*

High School*

College*

Name of last school attended

Date attended

List of training beyond high school

List area of Study and Degree

Certified nurse aide/orderly in Illinois?

Other licenses or certificates


Former Employers

List below your work experience starting with your present or most recent place of employment:

Employer #1

Job Title

From

To

Employer's Name & Address

Phone

Supervisor

Last Salary

Reason for leaving

Yes, I give Snyder Village permission to contact this employer for release of complete information.No, I do not grant permission for Snyder Village to contact this employer.

Employer #2

Job Title

From

To

Employer's Name & Address

Phone

Supervisor

Last Salary

Reason for leaving

Yes, I give Snyder Village permission to contact this employer for release of complete information.No, I do not grant permission for Snyder Village to contact this employer.

Employer #3

Job Title

From

To

Employer's Name & Address

Phone

Supervisor

Last Salary

Reason for leaving

Yes, I give Snyder Village permission to contact this employer for release of complete information.No, I do not grant permission for Snyder Village to contact this employer.

References

List three persons not related to you:

Reference #1

Name

Address

Phone

Years Acquainted

Reference #2

Name

Address

Phone

Years Acquainted

Reference #3

Name

Address

Phone

Years Acquainted

All three references not related to me. I authorize Snyder Village to contact all of my personal references I have provided on the application for full release of information. YesNo


Applicant's Statement

If employed, I agree to abide by Snyder Village rules and regulations. I understand that I will be on a 90 day probationary status at Snyder Village. I understand I will be required to take a pre-employment drug test, lift test and be subject to a fingerprinting and police background check. The above information is complete and true to the best of my knowledge. I understand that discovery of misrepresentation or omission of facts herein will be cause for immediate dismissal. I authorize this facility to contact any and/or all of my references for full information. I agree to take a physical examination as required by the State rules and regulations and agree that the examining physician may disclose the findings to this facility or an authorized agent of this facility. I understand and agree that this employment application, by itself or together with other company documents or policy statements, does not create a contract or employment.

Do you agree to the above applicant's statement?