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Background and
General Information
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* First Name:
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* Last Name:
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* Street Address 1:
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Street Address 2:
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* City:
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* State:
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* Zip Code:
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Telephone Number:
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Type:
(Home, Mobile, etc.)
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Alternate Telephone Number:
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Type:
(Home, Mobile, etc.)
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E-mail Address:
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* How did you learn about this position?
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If you were referred by a Presby employee, please list the name of the employee:
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* Please select the
positions you are
interested in.
Choose all that apply:
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Your selections:
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* Preferred work schedule
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* Available
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* Location: |
(Check all that apply. Must check at least one.) |
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Minimum salary required: |
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Are you at least age 18?
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* Do you have a valid driver's license?
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(If required for a position as Driver, Maintenance Staff
and/or Security Staff) |
Pennsylvania RN, LPN or LPGN license number:
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(If Applicable)
License expiration date:
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(Ex: 01/01/2010)
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Do you have any friends
or relatives now working for Presby's Inspired Life or an affiliated company? |
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* Are you currently employed with Presby's Inspired
Life?
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* Are you legally eligible to work in the United States?
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* Have you ever been disciplined or dismissed from employment
due to abuse of patients or residents? |
If yes, please explain and attach documentation regarding
any such dismissal.
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* Have you ever been convicted of a crime other than
a minor traffic violation?
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If yes, please explain.
**Please note: A criminal conviction is not an absolute bar to employment but will
be considered in relationship to specific job requirements.** |
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Resume and Cover Letter
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Completing this step will not allow you to skip the rest of
the application below. |
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Resume File Upload:
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Primary Educational Profile
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Highest Degree / Diploma / Achievement: |
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Institution/School: |
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Major/Field of Study: |
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GPA: |
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Additional Educational Profile
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2nd Highest Degree / Diploma / Achievement: |
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Institution/School: |
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Major/Field of Study: |
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GPA:
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Please list other Degrees/Certificates: |
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Please list Licenses and Certifications: |
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Enter Licenses / Certifications, Number, State, and Expiration: |
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Employment Experience
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* Have you applied for employment with Presby's Inspired
Life or an affiliated company within the past year? |
If yes, when and where?
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* Have you ever been employed by Presby's Inspired Life
or an affiliated company? |
If yes, list the locations where you worked,
the dates of your employment and the Supervisor.
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Name of Location or Worksite: |
Dates:
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to
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(Ex: 01/01/2000)
Supervisor:
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* Are you currently employed? |
If yes, where?
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Date of hire:
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(Ex: 01/01/2000)
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* Have you ever received disciplinary action and/or
been discharged from any place of employment? |
If yes, where?
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Employment History
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Please list your job history for the past fifteen years or last four employers,
starting with your present or most recent employment and noting any periods in which
you were not employed in the section marked "Additional Information". Please include
military service; do not include internships
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Most recent employer |
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Name of Employer: |
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Street Address: |
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City, State, Zip: |
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Position Title: |
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From (mo/yr): |
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To (mo/yr): |
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Last Salary: |
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Supervisor's Name: |
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Supervisor's Title: |
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Supervisor's Phone: |
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Employment Status: |
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Describe your principal duties or responsibilities: |
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Reason for leaving: |
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If present employer, may we contact?
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Next most recent employer |
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Name of Employer: |
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Street Address: |
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City, State, Zip: |
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Position Title: |
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From (mo/yr): |
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To (mo/yr): |
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Last Salary: |
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Supervisor's Name: |
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Supervisor's Title: |
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Supervisor's Phone: |
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Employment Status: |
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Describe your principal duties or responsibilities: |
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Reason for leaving: |
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If present employer, may we contact?
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Next most recent employer |
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Name of Employer: |
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Street Address: |
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City, State, Zip: |
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Position Title: |
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From (mo/yr): |
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To (mo/yr): |
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Last Salary: |
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Supervisor's Name: |
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Supervisor's Title: |
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Supervisor's Phone: |
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Employment Status: |
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Describe your principal duties or responsibilities: |
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Reason for leaving: |
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If present employer, may we contact?
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Next most recent employer |
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Name of Employer: |
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Street Address: |
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City, State, Zip: |
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Position Title: |
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From (mo/yr): |
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To (mo/yr): |
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Last Salary: |
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Supervisor's Name: |
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Supervisor's Title: |
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Supervisor's Phone: |
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Employment Status: |
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Describe your principal duties or responsibilities: |
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Reason for leaving: |
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If present employer, may we contact?
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Certification and Acknowledgement
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I certify that the information I am providing to Presby's Inspired Life in applying
for employment is true and correct to the best of my knowledge. I voluntarily give
Presby's Inspired Life the right to make a thorough investigation of my entire work
history and to verify all information given in my application for employment, related
papers, and oral interview. I authorize such an investigation and the giving and
receiving of any such information. I release all persons, companies and institutions
from liability or responsibility in connection with the verification of the information
I have provided. I understand that any false statement, misrepresentation or deliberate
omission of a fact in connection with this application may result in my not being
hired, or, if I am employed, may result in termination of my employment with Presby's
Inspired Life.
* Inititals:
I also understand that the submission of this completed application to Presby's
Inspired Life does not mean that a position is available nor that I will receive
an offer of employment. I understand that if I am employed by Presby's Inspired
Life, I am subject to an initial probationary period for a maximum of ninety (90)
days. I understand that an offer of employment does not guarantee employment for
a definite time period nor does it guarantee that I will be employed for a particular
job, site, unit, department, schedule or shift. I understand that Presby's Inspired
Life can change wages, benefits and conditions of employment at any time. I further
understand that no employment contract is being offered and that my employment can
be terminated with or without good cause and with or without prior notice, by either
me or Presby's Inspired Life. I understand that all employment with Presby's Inspired
Life is at-will.
* Inititals:
I also understand that a conditional employment offer may be made, after which Presby's
Inspired Life may require a medical examination or medical tests in order to comply
with regulatory and government licensing standards.
* Inititals:
I also understand that all offers of employment are contingent upon successful completion
of a pre-employment drug test, criminal background check, and any other required
clearance (OIG & PA's Megan's Law).
* Inititals:
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* Signature: |
Filling out the above field is the equivalent of your handwritten
signature.
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* Date: |
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(Ex: 01/01/2010)
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please leave the following field empty
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