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About us
Services
- Community Based Habilitation
- Residential Habilitation
Careers
Apply online
Contact

Application For Employment

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PERSONAL INFORMATION

First Name

Middle Name

Last Name

Other names used

Are you legally entitled to work in the U.S.?

Yes No

Have you ever been convicted of a felony?

Yes No

Are you 18 Years of age or older?

Yes No

Are you currently employed?

Yes No

Have you ever been employed by Safe Harbor Care Services?

Yes No

Are you related to any current Safe Harbor Care Services Employee?

Yes No

If required for position, do you have a valid Driver License?

Yes No

If required for position, do you have a valid Proof of Insurance?

Yes No

How did you learn about this employment opportunity at Safe Harbor Care Services? Check all that apply

Job Fair Walk-In Employee Website Other

POSITION

Position Applying for

C.N.A Q.M.A L.P.N R.N Administration

mm/dd/yyyy

Applying for

Full-Time Part-Time Temporary Days Evenings Nights

Available to work

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Would you be able to perform the essential functions of the job you are applying for, with or without reasonable accommodation?

Yes No

EDUCATION AND TRAINING

School Name

City / State

Dates Attended Month/Year (From)

Dates Attended Month/Year (To)

Did you Graduate?/Year (To)

If no, # of years left to graduate

Degree received

Major

Click if no post-education

Other credentials - Licenses / Certifications or professional affiliations, etc., which are relevant to the job(s) for which you are applying.

Type of License / Certification

License and Certification # and State Issued

Expiration Date

Special Skills you have to offer for this position

EMPLOYMENT HISTORY (Begin with Most Recent Employment)

Employer #1 (Company Name)

Job Title & Duties

From

To

Supervisor’s Name

Phone

Address

Reason for leaving

May We Contact This Employer?

Yes No

Employer #2 (Company Name)

Job Title & Duties

From

To

Supervisor’s Name

Phone

Address

Reason for leaving

May We Contact This Employer?

Yes No

Employer #3 (Company Name)

Job Title & Duties

From

To

Supervisor’s Name

Phone

Address

Reason for leaving

May We Contact This Employer?

Yes No

REFERENCES:

Give names of three Persons NOT related to you. Two of your References MUST be supervisory or Professional.

Name

Phone

Address

Occupation

The information on this application is true, and accurate to the best of my knowledge.

Full Name

Date

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Contact:

+88 666 888 0000
+88 769 818 0000
[email protected]
666 road, broklyn golden street
new york 600