Name:

Last First Middle

Address: City State Zip Other names under which you have been employed:

Telephone number Cell phone number SS# Email Position Applying for: Part Time Full Time Shift Days Available for work LPN 7 a.m. 3 p.m. 11 p.m. 7 a.m.

3 p.m. 11 p.m.

Sun Mon Tues Wed Thu Fri Sat

C NA 7 a.m. 3 p.m. 11 p.m. 7 a.m.

3 p.m. 11 p.m.

Sun Mon Tues Wed Thu Fri Sat

RN 7 a.m. 3 p.m. 11 p.m. 7 a.m.

3 p.m. 11 p.m.

Sun Mon Tues Wed Thu Fri Sat

Cook Breakfast Lunch Dinner Sun Mon Tues Wed Thu Fri Sat Wait staff Breakfast Lunch Dinner Sun Mon Tues Wed Thu Fri Sat Utility Breakfast Lunch Dinner Sun Mon Tues Wed Thu Fri Sat Housekeeper

Floor care

Maintenance Tech

Security

Other

Brandon Wilde

4275 Owens Road

Evans, GA 30809

706-***-****

Fax 706-***-****

Job Line 706-***-****

www.brandonwilde.com

Applicants requiring reasonable accommodation for the application and/or interview process should notify the Human Resources Department Date available for work Minimum wage required Are you legally eligible to work in this country? Yes No If under 18, and it is required, can you furnish a work permit? Yes No Are you currently employed by University Hospital, Kentwood or Westwood, Yes No Crothall-UH Plant Services, Crothall-UH EnvSvcs or Morrison Dietary Svcs? Have you been employed by University Hosp, Kentwood, Westwood, Brandon Wilde? Yes No If yes, circle appropriate one and list dates of employment Referred by:

Relative employed at Brandon Wilde? Department: Relationship: APPLICATION FOR EMPLOYMENT

Employer Phone Address Job Title City/State/ZIP Summarize nature of work performed Immediate Supervisor Title Hourly rate/salary : Dates Employed: Start: End: Reason for leaving WORK HISTORY: List present or most recent employer first. (Include military employment, temporary, PRN and part-time employment as well as full-time positions for the past five years). Employer Phone Address Job Title City/State?ZIP Summarize nature of work performed Immediate Supervisor Title Hourly rate/salary : Dates Employed: Start: End: Reason for leaving Employer Phone Address Job Title City/State/ZIP Summarize nature of work performed Immediate Supervisor Title Hourly rate/salary : Dates Employed: Start: End: Reason for leaving Employer Phone Address Job Title City/State/ZIP Summarize nature of work performed Immediate Supervisor Title Hourly rate/salary : Dates Employed: Start: End: Reason for leaving Skills and Qualifications Please complete information below for any current license required for the position in which you are applying.

CNA License number Other LPN License number Date obtained RN License number License number Total number of years experience in the same job for which you are applying Summarize any job related training, skills, licenses and or certifications Education

School Attended Number of Years

Completed

Diploma/Degree Course of Study

High School

Undergraduate College

Graduate College

Professional School/

Training/Other

Professional School/

Training/Other

Professional School/

Training/Other

References - Please provide name, address and phone number for three work references. Name Telephone Number Address Relationship Name Telephone Number Address Relationship Name Telephone Number Address Relationship Applicant Statement

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all ref- erences, personal and professional, employers, public agencies, licensing authorities and educational institutions and to otherwise verify the ac- curacy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims that I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. I understand that this application remains current for 60 days. At the conclusion of that time, if I have not heard from the employer and wish to be considered for employment, it will be necessary to reapply. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no su- pervisor or representative of Brandon Wilde is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the CEO/President of Brandon Wilde. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that feder- al law requires me to complete the I-9 form in this regard. I certify that the answers given by me to the forgoing questions and statements are true, correct and without omissions. Never has it been shown by credible evidence (e.g. a court or jury, a department investigation, or other reliable evidence) that I have abused, neglected, sexually assault- ed, exploited, or deprived any person or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct. If, upon investigation, anything contained in this application is found to be untrue, incomplete or misrepresented in any respect, it will be suffi- cient cause to cancel further consideration of this application or immediately terminate my employment, whenever it is discovered. I understand that present and future representation made to me regarding pay, benefits and policies does not create a contract of em- ployment. I CERTIFY THE ABOVE ANSWERS ARE TRUE TO THE BEST OF MY KNOWLEDGE. I certify that I have read, fully understand and accept all terms of the foregoing applicant statement. Signature of Applicant Date Have you ever plead “guilty” or “no contest” to a crime? Yes No If yes, please explain in detail Have you ever been convicted of a crime? Yes No

If yes, please explain in detail Answering yes to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, nature of the violation, rehabilitation and position applied for will be taken into consideration. Sept 2012