Apply for GNA - DAY SHIFT

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Summary
Title:GNA - DAY SHIFT
ID:113009
Company:Fahrney Keedy Memorial Home
Department:Nursing Skilled
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Contact Information
* Referral Source:
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* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
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Application for Employment
PERSONAL INFORMATION
Yes   No
Yes   No
Yes   No
Yes   No
EMPLOYMENT DESIRED
Full Time   Part Time   Seasonal
Yes   No
Yes   No
EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School 1

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School 2

Yes   No

School 3

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School 4

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School 5

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EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment

Employer 1

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Employer 2

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Employer 3

Yes   No

Employer 4

Yes   No

Employer 5

Yes   No
REFERENCES

Please provide three references (not relatives).

Reference 1

Reference 2

Reference 3
AUTHORIZATION

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

Fahrney Keedy EEO
Statement of Compliance---- Fahrney-Keedy Senior Living Community provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics or any other legally protected group status. In addition to federal law requirements, Fahrney-Keedy complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leave of absence, compensation and training. Fahrney-Keedy Senior Living Community fully complies with the requirements of the Rehabilitation Act of 1973. Under the law, Fahrney-Keedy will provide reasonable accommodations to qualified employees or applicants with disabilities, unless to do so would cause undue hardship. Fahrney-Keedy is committed to providing reasonable accommodations to its employees and applicants for employment to ensure that individuals with disabilities enjoy equal access to all employment opportunities. Fahrney-Keedy Senior Living Community expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of Fahrney-Keedy’s employees to perform their job duties may result in discipline up to and including discharge. According to our Human Resources Policies, Fahrney-Keedy Senior Living Community may verify all statements made by you or contained in your application and/or resume. Such verifications may incorporate an examination of educational credentials, criminal convictions and driving records as required by the responsibilities of your position. Under Maryland law, an employer may not require or demand, as a condition of employment, prospective employment, or continued employment, that an individual submit to or take a polygraph examination or similar test. An employer who violates this law is guilty of a misdemeanor and subject to a fine not exceeding $ 100. Voluntary EEO Identification Various agencies of the United States Government require employers to maintain information on applicants pertaining to factors such as race, sex, and type of position for which an individual applies. The information requested on this sheet is for compliance with certain record keeping requirements and will not be used in determining an applicant’s abilities. Fahrney-Keedy Senior Living Community believes all persons are entitled to equal employment opportunities and does not discriminate against employees or applicants for employment because of race, color, religion, sex, national origin, age, disability, genetics, or any other legally protected group status. If an offer of employment is extended, the offer would be contingent upon successful completion of: 1) a negative drug screen; 2) satisfaction of the Employee Health Assessment requirements, including, but not limited to, a negative TB and Hepatitis test; 3) reference checks; and 4) a criminal background check with no negative findings. Regulations issued by the U.S. Department of Labor with respect to disabled individuals, disabled veterans, and Vietnam Era veterans require that federal contractors provide an opportunity for self-identification to candidates seeking employment. Such self-identification is submitted on a voluntary basis, on a confidential basis, for the use only in accordance with regulations, and without subjecting the individual to adverse treatment. Voluntary EEO Identification Various agencies of the United States Government require employers to maintain information on applicants pertaining to factors such as race, sex, and type of position for which an individual applies. The information requested on this sheet is for compliance with certain record keeping requirements and will not be used in determining an applicant’s abilities. Fahrney-Keedy Senior Living Community believes all persons are entitled to equal employment opportunities and does not discriminate against employees or applicants for employment because of race, color, religion, sex, national origin, age, disability, genetics, or any other legally protected group status.
* Sex
Male   Female
Ethnicity
Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Cantal American, or other Spanish culture or origin regardless of race;
White / Caucasian (Not Hispanic or Latino) – A person having origins in any of the original people of Europe, North Africa, or the Middle East;
Black / African-American (Not Hispanic or Latino) – A person having origins in any of the Black racial groups of Africa;
Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam;
American Indian or Alaskan Native (Not Hispanic or Latino) – A person having origins in the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community recognition;
Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands;
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Individual with a Disability
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
I Choose Not to Respond

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