Part-Time United States

EMPLOYMENT APPLICATION

Presbyterian Homes of Georgia, Inc. is an Equal Opportunity Employer. It is the policy of Presbyterian Homes of Georgia, Inc. not to discriminate in hiring and employment on the basis of race, color, religion, national origin, sex, disability or age in accordance with all applicable federal, state and local laws. No question on this application is intended to secure information for an unlawful purpose. PERSONAL INFORMATION

Name

LAST FIRST MIDDLE

Current Street Address

City State Zip County

Home Phone Mobile Phone E-Mail Address

Social Security Number

AVAILABILITY FOR WORK

Position(s) applied for

Desired Salary Date available for work

Please check shift preference(s): Day Evening Night Weekends Please check preferred work status: Full-Time Part-Time PRN Please specify work days and hours, if other than Full-Time YES NO

Are you available to work on weekends and holidays? If under age 18, do you have a work permit?

Are you able to show proof that you are authorized to work in the United States? FOR OFFICE USE ONLY

Presbyterian Homes of Georgia, Inc. Facility Name: Calvin Court – Atlanta, GA Philips Tower – Decatur, GA Presbyterian Home – Quitman, GA Presbyterian Village – Austell, GA EDUCATION

Circle the highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 Equivalent Exam (List) Name and location of high school attended:

List College(s), Vocational-Technical School(s) or other appropriate school(s) attended: SCHOOL LOCATION MAJOR DEGREE

PROFESSIONAL REGISTRATION, LICENSE AND ACCREDITATION STATE REGISTRATION

NUMBER ISSUE DATE EXPIRATION DATE TYPE OF LICENSE

Please list any certifications you possess (CNA, ACLS, CCRN, etc.): GENERAL

YES NO

Have you ever been convicted of a crime, other than a traffic offense?

(Conviction of a crime is not an automatic bar to employment and will be considered only if job related. Furthermore, all circumstances will be considered.) If yes, please explain

YES NO

Have you ever applied for a position with a Presbyterian Homes of Georgia, Inc. facility? If yes, when? What position?

YES NO

Have you ever been employed by a Presbyterian Homes of Georgia, Inc. facility? If yes, when? Position held:

What was your reason for leaving?

EMPLOYMENT EXPERIENCE

Please list your last five (5) employers, beginning with your most recent employment. If, at any time, you did not work for more than three (3) months between employers, please list the reason and length of time for this inactivity. 1. Employer Ending Salary $

Address

Title Employed: From: / To: / MONTH YEAR MONTH YEAR

Supervisor’s Name Phone Describe Duties

Reason for leaving May we contact employer: Yes or No If no, please explain. 2. Employer Ending Salary $

Address

Title Employed: From: / To: / MONTH YEAR MONTH YEAR

Supervisor’s Name Phone Describe Duties

Reason for leaving May we contact employer: Yes or No If no, please explain. 3. Employer Ending Salary $

Address

Title Employed: From: / To: / MONTH YEAR MONTH YEAR

Supervisor’s Name Phone Describe Duties

Reason for leaving May we contact employer: Yes or No If no, please explain. 4. Employer Ending Salary $

Address

Title Employed: From: / To: / MONTH YEAR MONTH YEAR

Supervisor’s Name Phone Describe Duties

Reason for leaving May we contact employer: Yes or No If no, please explain. 5. Employer Ending Salary $

Address

Title Employed: From: / To: / MONTH YEAR MONTH YEAR

Supervisor’s Name Phone Describe Duties

Reason for leaving May we contact employer: Yes or No If no, please explain. IF ADDITIONAL SPACE IS REQUIRED, PLEASE USE SEPARATE PAPER AND ATTACH. CLERICAL AND OFFICE APPLICANTS

Please list computer skills you possess:

Typing/WPM 10 Key

Computer Experience

Software Experience Other

MILITARY EXPERIENCE

Branch of U. S. Armed Forces Served

Dates of Duty: From: To:

Duties

Rank at Discharge Type of Discharge

REFERENCES

Please list three (3) professional references (local, if possible) who have known you over 3 years. Please do not include relatives.

NAME OF REFERENCE YEARS KNOWN CONTACT NUMBER

1. ( )

2. ( )

3. ( )

ADDITIONAL INFORMATION

Additional information you feel may help us in placing you in a position : I understand that Presbyterian Homes of Georgia, Inc. may contact all persons, schools, and employers, current or former, to verify my employment or obtain information that may be required to arrive at an employment decision. I hereby release Presbyterian Homes of Georgia, Inc. and the aforementioned who provide such information from any liability or damages regarding the provision of such information. Other than where employment is governed by an applicable collective bargaining agreement, I acknowledge that my employment may be terminated with or without cause, and with or without notice, at any time, at the option of either Presbyterian Homes of Georgia, Inc. or myself. I understand that no representative of Presbyterian Homes of Georgia, Inc., other than Senior Management, has any authority to enter into any agreement that contradicts or modifies the foregoing in any manner. Any written or oral statements to the contrary are hereby expressly disavowed and should not be relied upon by current or prospective employees.

I acknowledge that consent to and successful completion of a drug test upon request at any time is a condition of employment and continued employment with Presbyterian Homes of Georgia, Inc. I hereby release Presbyterian Homes of Georgia, Inc. and any individuals who administer such tests from any and all liability and damages resulting from the administration of and reliance upon the results of any tests. I hereby declare the information provided by me in this application for employment as true, correct and complete to the best of my knowledge. I understand that if employed, any misstatement or omission of fact on this application shall be considered cause for discharge. Applicant Signature Date

Please realize that incomplete applications will not be considered. We thank you for your interest in working with us. Have a good day.

Contact this candidate