Nightingale Nursing & Caregiving || www.homehealthnursing.com

If you are interested in employment with Nightingale Nursing & Caregiving, please take a moment to fill out our application below.

Name:
Home Phone:		Work Phone:
Address:
City:
State/Province:
Zip/Postal:
Country:
E-Mail:

Nightingale Nursing & Caregiving
1903 South Russell
Missoula, MT 59801- 6603

Instructions

If you need help to fill out this application form or for any phase of the employment process, please notify us by clicking here, and every effort will be made to accommodate your needs in a reasonable amount of time.

1. Please read "applicant Note".
2. Complete this form in its entirety.


APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements and/or omissions during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination because of sex, marital status, race, age, creed, national origin or the presence of disabilities. A felony conviction will not necessarily bar an applicant from employment. Testing of job related skills and for the presence of drugs in your body may be required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.

For which position are you applying?
AVAILABILITY: What hours can you work on a 24 hour basis?	Shift Hours:
What date can you start? What category would you prefer?
Have you ever worked for Nightingale Nursing & Caregiving?
If Yes, for what company?
If Yes, What name did you use?

EDUCATION:
Please select highest grade completed:
NAME	CITY/STATE	GRADUATE?
HIGH SCHOOL
COLLEGE
OTHER

JOB RELATED SKILLS: NOTE: Do not fill out any part of this section you believe to be non-job related

List languages in which you are fluent:

If the job requires, do you have the appropriate valid drivers license?

DL# Type: State:

Please list any other skills, licenses or certificates that may be job-related or that you feel would be of value to this job or company:

	Can you perform the requirements of this job with or without reasonable accommodation?
	Have you ever been convicted of a felony?

EMPLOYMENT REFERENCES
Your application may not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical.

MOST RECENT EMPLOYER
^{COMPANY NAME}
^CITY	^STATE	^{PHONE NUMBER}
^{DATES EMPLOYED}	^{JOB TITLE}	^{SUPERVISOR'S NAME}
^{DUTIES OF POSITION}
Are you currently working for this employer?
If yes, may we contact them?
^SALARY	^{REASON FOR LEAVING}

SECOND MOST RECENT EMPLOYER
^{COMPANY NAME}
^CITY	^STATE	^{PHONE NUMBER}
^{DATES EMPLOYED}	^{JOB TITLE}	^{SUPERVISOR'S NAME}
^{DUTIES OF POSITION}
^SALARY	^{REASON FOR LEAVING}

THIRD MOST RECENT EMPLOYER
^{COMPANY NAME}
^CITY	^STATE	^{PHONE NUMBER}
^{DATES EMPLOYED}	^{JOB TITLE}	^{SUPERVISOR'S NAME}
^{DUTIES OF POSITION}
^SALARY	^{REASON FOR LEAVING}

PERSONAL REFERENCES Include only individuals who are familiar with your work ability. Do not include relatives.
NAME	ADDRESS/PHONE	YEARS KNOWN/RELATIONSHIP
1.
2.
3.

ADDITIONAL COMMENTS

CERTIFICATION AND RELEASE I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

^SIGNATURE	^DATE
NOTE: Your typed name in the signature box is a legal representation of your signature.