Online Application

Upload Resume
Max. file size: 25 MB.
Required * fields must be filled out.
Full Name (First, Middle, Last)*
Have you been employed under a different name?*
- Yes
- No
Please list names used:
Street Address*
City, State, Zip*
Email*
Phone*
Alternate Phone Number
Position Applied For*
Are you at least 18 years old?*
- Yes
- No
On what date would you be available to start work?*
MM slash DD slash YYYY
Are you Available to work:*
- Select All
- Full Time
- Part Time
- Occasional/Seasonal
- Day Shift
- PM Shift
- Night Shift
- Weekends
How did you learn of our organization?*
Name of relatives employed here:
Have you filed an application here before?*
- Yes
- No
If yes, when:*
MM slash DD slash YYYY
Have you been employed here before?*
- Yes
- No
If yes, when:*
MM slash DD slash YYYY
If previously employed, reason for leaving:*
Education
High School Name:
High School Location: City, State
Number of years completed:
Course of study:
Certification or degree:
College
College Name:
College Location: City, State
Number of years completed:
Course of study:
Certification or degree:
College 2
College Name:
College Address: City, State
Number of years completed:
Course of study:
Certification or degree:
Other School
Other School Name:
Other School Address: City, State
Number of years completed:
Course of study:
Certification or degree:
Licenses/ Certifications Held (e.g. CNA, LPN, RN, etc.)
Type
Number
State, Country
Expiration Date
MM slash DD slash YYYY
Please describe additional job-related seminars, skills, or qualifications
References
Give name, address, and phone number of three references not related to you.
Reference #1 Name*
Address: City, State
Phone*
Email
Reference #2 Name*
Address: City, State
Phone*
Email
Reference #3 Name*
Address: City, State
Phone*
Email
Employment
May we communicate with your present employer?*
- Yes
- No
Employment start date:
MM slash DD slash YYYY
Employment end date:
MM slash DD slash YYYY
Employer Name:
Employer Address: Street, City, State, Zip
Employer Phone Number
Immediate supervisor:
Job Title
Final wage:
Duties
Reason for leaving:
Previous Employer
Employer Name:
Employer Address: Street, City, State, Zip
Employer Phone Number
Immediate supervisor:
Job Title
Employment start date:
MM slash DD slash YYYY
Employment end date:
MM slash DD slash YYYY
Duties
Final wage:
Reason for leaving:
Previous Employer #2
Employer Name:
Employer Address: Street, City, State, Zip
Employer Phone Number
Immediate supervisor:
Job Title
Employment start date:
MM slash DD slash YYYY
Employment end date:
MM slash DD slash YYYY
Duties
Final wage:
Reason for leaving:
Previous Employer #3
Employer Name:
Employer Address: Street, City, State, Zip
Employer Phone Number
Immediate supervisor:
Job Title
Employment start date:
MM slash DD slash YYYY
Employment end date:
MM slash DD slash YYYY
Duties
Final wage:
Reason for leaving:
As a condition of employment, are you willing to receive a seasonal flu shot?*
- Yes
- No
Do you have the legal right to be employed in the U.S.?*
- Yes
- No
NOTE: Providing the following information will not result in automatic disqualification of employment.
Have you ever been convicted of a felony, misdemeanor, or ordinance violation other than a traffic violation?*
- Yes
- No
Please explain:*
Are there charges pending against you?*
- Yes
- No
Please explain:*
By typing your name here, using any device means, or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.
Date*
MM slash DD slash YYYY
NOTICE TO APPLICANTS - Please read each paragraph carefully before signing:
- I certify that this application was completed by me and all information provided by me in support of my application for employment is true and correct to the best of my knowledge.
- I understand that misrepresentations, omissions, false or evasive information may be cause for rejection, or may be cause for subsequent dismissal if I am hired.
- I understand that an offer of employment extended to me will be contingent based on satisfactory physical examination including TB skin test or chest x-ray, a drug screen, employment references, and criminal background check (a criminal record does not constitute an automatic bar to employment and will be considered only as it relates to the job).
- I hereby authorize any former employer, person, firm, corporation, or government agency to answer any and all questions regarding my application and to release or provide any information within their knowledge or records. I agree to hold any or all of them blameless and free of any liability for releasing any truthful information that is within their knowledge or records.
- I understand my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either Shorehaven or myself. I understand that no representative of Shorehaven, other than the CEO, has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.
By typing your name here, using any device means, or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.
E-Signature of Applicant:*