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LOCATION

DATE

MM slash DD slash YYYY

PERSONAL INFORMATION

NAME

First Middle Last

OTHER NAME USED WHILE WORKING

ADDRESS

Street Address City State / Province / Region ZIP / Postal Code

HOME TELEPHONE NUMBER

ARE YOU A U.S. CITIZEN OR ARE YOU AUTHORIZED BY THE INS TO WORK?

YES

HAVE YOU EVER BEEN GUILTY OR BEEN CONVICTED OF ANYTHING OTHER THAN TRAFFIC VIOLATIONS? IF YES, PLEASE EXPLAIN

SOME FACILITIES MAY HAVE SMOKE FREE ENVIRONMENTS, WOULD YOU AGREE TO WORK IN SUCH A FACILITY?

YES

EMPLOYMENT DESIRED

HAVE YOU EVER APPLIED FOR EMPLOYMENT AT THIS OR OTHER PRIORITY MANAGEMENT FACILITIES BEFORE? IF SO, INCLUDE NAME(S) OF THE FACILITY(IES) AND DATES

IF YOU HAVE WORKED AT A NURSING FACILITY BEFORE, PLEASE LIST THE NAME(S) OF THE FACILITY(IES) AND THE DATES

DATE YOU CAN START

MM slash DD slash YYYY

STARTING SALARY DESIRED

POSITION DESIRED

SHIFT DESIRED

ANY SHIFT YOU ARE NOT WILLING TO WORK?

HAVE YOU EVER BEEN EXCLUDED FROM PARTICIPATING IN ANY FEDERAL OR STATE HEALTH CARE PROGRAM?

YES

ARE YOU EMPLOYED NOW?

YES

IF SO, MAY WE CONTACT YOUR EMPLOYER?

YES

ARE YOU CURRENTLY ON LAYOFF OR LEAVE FROM ANOTHER COMPANY?

YES

ARE YOU AVAILABLE FOR FULL TIME WORK?

YES

ARE YOU AVAILABLE FOR PART TIME WORK?

YES

LIST APPLICABLE SKILLS OR LICENSES

EDUCATION

HIGHEST GRADE OR DEGREE COMPLETED (LIST PARTIAL DEGREE ALSO)

NAME AND LOCATION OF LAST SCHOOL ATTENDED

ANY VOCATIONAL OR TRADE TRAINING?

LIST ANY ADDITIONAL SKILL, TRAININ, EXPERIENCE, OR OTHER QUALIFICATIONS RELATED TO THE POSITION WHICH YOU ARE APPLYING

REFERENCES

REFERENCE 1 - NAME

REFERENCE 1 - ADDRESS

REFERENCE 1 - PHONE

REFERENCE 1 - YEARS ACQUAINTED

REFERENCE 2 - NAME

REFERENCE 2 - ADDRESS

REFERENCE 2 - PHONE

REFERENCE 2 - YEARS ACQUAINTED

EMERGENCY (IN CASE OF EMERGENCY CONTACT)

EMERGENCY CONTACT - NAME

EMERGENCY CONTACT - ADDRESS

EMERGENCY CONTACT - PHONE

EMERGENCY CONTACT - RELATIONSHIP TO YOU

EMPLOYMENT HISTORY

NAME OF COMPANY 1

ADDRESS OF COMPANY 1

CONTACT PHONE NUMBER

DATES WORKED AT COMPANY 1

DESCRIBE THE WORK YOU DID

BEGINNING SALARY

ENDING SALARY

REASON FOR LEAVING

SUPERVISOR

ADDITIONAL EMPLOYMENT HISTORY (IF APPLICABLE)

NAME OF COMPANY 2

ADDRESS OF COMPANY 2

CONTACT PHONE NUMBER

DATES WORKED AT COMPANY 2

DESCRIBE THE WORK YOU DID

BEGINNING SALARY

ENDING SALARY

REASON FOR LEAVING

SUPERVISOR

NAME OF COMPANY 3

ADDRESS OF COMPANY 3

CONTACT PHONE NUMBER

DATES WORKED AT COMPANY 3

DESCRIBE THE WORK YOU DID

BEGINNING SALARY

ENDING SALARY

REASON FOR LEAVING

SUPERVISOR

NAME OF COMPANY 4

ADDRESS OF COMPANY 4

CONTACT PHONE NUMBER

DATES WORKED AT COMPANY 4

DESCRIBE THE WORK YOU DID

BEGINNING SALARY

ENDING SALARY

REASON FOR LEAVING

SUPERVISOR

PLEASE READ AND COMPLETE BEFORE SIGNING

ALL STATEMENTS MADE BY ME ON THIS APPLICATIONA RE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND THAT I HAVE WITHHELD NOTHING WHICH, IF DISCLOSED, WOULD AFFECT THIS APPLICATION UNFAVORABLY. I AGREE THAT THIS FACILITY AND MY PREVIOUS EMPLOYERS SHALL NOT BE HELD LIABLE IN ANY RESPECT IF A JOB OFFER IS NOT EXTENDED, IS WITHDRAWN, OR MY EMPLOYMENT IS TERMINATED BECAUSE OF FALSE STATEMENTS, OMISSIONS OR ANSWERS MADE BY ME ON THIS APPLICATION.

AGREE

DISAGREE

I AUTHORIZE MY PREVIOUS EMPLOYERS, SCHOOLS OR PERSONS NAMED AS REFERENCES TO GIVE ANY INFORMATION REGARDING EMPLOYMENT OR EDUCATIONAL RECORD

AGREE

DISAGREE

I UNDERSTAND THAT OPERATING CONDITIONS MAY REQUIRE ME TO TEMPORARILY WORK SHIFTS OTHER THAN THE ONE FOR WHICH I AM APPLYING AND I AGREE TO SUCH SCHEDULING CHANGES AS DIRECTED BY MY SUPERVISOR OR THE FACILITY ADMINISTRATOR.

AGREE

DISAGREE

IN THE EVENT OF MY EMPLOYMENT I AGREE TO COMPLY WITH ALL RULES AND REGULATIONS AS SET FORTH IN ANY COMMUNICATION DISTRIBUTED TO EMPLOYEES.

AGREE

DISAGREE

I AGREE TO PROVIDE THE REQUIRED DOCUMENTATION TO COMPLY WITH THE IMMIGRATION AND CONTROL ACT OF 1986 ON OR BEFORE THE FIRST DAY OF EMPLOYMENT.

AGREE

DISAGREE

I UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT IS "AT WILL" AND IF FOR NO DEFINITE PERIOD AND MAY BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE.

AGREE

DISAGREE

I AGREE AS A CONDITION OF INITIAL AND CONTINUED EMPLOYMENT, TO SUBMIT TO SUBSTANCE ABUSE TESTING (SUCH AS ALCOHOL, DRUGS, ETC) AT ANYTIME AT THE REQUEST ODF MY EMPLOYER AND I UNDERSTAND THAT REFUSAL TO SUBMIT TO SUBSTANCE ABUSE TESTING MAY BE GROUNDS FOR IMMEDIATE DISMISSAL..

AGREE

DISAGREE

CAN YOU PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITION FOR WHICH YOU ARE APPLYING?

AGREE

DISAGREE

SIGNATURE (PLEASE TYPE YOUR FULL NAME TO SIGN)

DATE SIGNED

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.

Priority Management’s facilities offer health care for adults who are recovering from serious illness, those who need rehabilitation after an injury or illness, and those who need skilled nursing care in a residential environment. We strive to deliver optimal, individualized nursing care to each patient we see, and to create a workplace where each employee is valued and respected. This commitment by our management, staff and physicians allows us to provide quality residential nursing care.

Contact Us

Name*
First Last
Email*
Phone*
Message
Comments
This field is for validation purposes and should be left unchanged.

Home
About
- News
- Reviews
Amenities
Services
- Assisted Living Levels of Care
Information for Families
Request A Tour
Careers
Contact

(318) 861-2366
Contact

Application Form

PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION

REFERENCES

EMERGENCY (IN CASE OF EMERGENCY CONTACT)

EMPLOYMENT HISTORY

ADDITIONAL EMPLOYMENT HISTORY (IF APPLICABLE)

PLEASE READ AND COMPLETE BEFORE SIGNING

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