Application | Holmes Lake Rehabilitation and Care Center

Step 1 of 8

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Name*
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email

Education
High School
College
Degree
Year Graduated
Tech School
Degree
Year Graduated
Volunteer work or other skills
Why would you like to work at Holmes Lake Rehabilitation & Care Center?

Employment History: Complete employment history is required. List all work experience beginning with the most RECENT position. Please complete even if a resume is attached.
List any current or past employer's you DO NOT want us to contact
Employer 1
Employeer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Supervisor Name
First Last Title
Dates of employment
Start
End
Starting Pay
Ending Pay
Describe your duties
Reason for leaving
Employer 2
Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Supervisor Name
First Last Title
Start
End
Starting Pay
Ending Pay
Describe your duties
Reason for leaving
Employer 3
Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Supervisor Name
First Last Title
Start
End
Starting Pay
Ending Pay
Describe your duties
Reason for leaving
Employer 4
Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Supervisor Name
First Last Title
Start
End
Starting Pay
Ending Pay
Describe your duties
Employer 5
Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Supervisor Name
First Last Title
Start
End
Starting Pay
Ending Pay
Describe your duties
Reason for leaving

Personal References: list three references. Do not list any relatives
Reference 1
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Occupation
Reference 2
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Occupation
Reference 3
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Occupation

I understand that Holmes Lake Rehabilitation & Care Center will request information as to my character, work habits, performance, along with reasons for termination of past employment. I understand that as directed by company policy and consistent with the job described, information will be requested from public and private sources about my: criminal history, court record, credentials, and references.

I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, employer, or insurance company contacted to furnish the above mentioned information. In addition, I hereby waive the right to bring any cause of action against these individuals for defamation, invasion of privacy or any other reason because of their statements.

I agree to submit to a pre-employment physical and I understand that successful completion of the physical, along with favorable reports from APS, CPS, and criminal history will be a condition of my employment.

I hereby release Holmes Lake Rehabilitation & Care Center and their agents and all persons, agencies and entities providing information or reports about me from any and all liability arising out of the requests for or release of any of the above mentioned information or reports. I certify that my answers to the foregoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading or otherwise incorrect statements made on this application form or during any interview may be grounds for my immediate discharge.

I acknowledge that a facsimile (FAX) or photographic copy shall be as valid as the original.

I agree that, if I am employed, I will abide by all the rules and regulations of Holmes Lake Rehabilitation & Care Center. I understand that nobody at Holmes Lake Rehabilitation & Care Center is authorized to enter into any written or verbal employment contract with me for any definite period of time without the express written consent of the Administrator. I also understand that my employment is "at-will" and may be terminated by myself or by Holmes Lake Rehabilitation & Care Center at any time for any reason or no reason at all, with or without prior notice.

Holmes Lake Rehabilitation & Care Center demands honesty from its employees and prospective employees. Any form of dishonesty is grounds for discharge.

Step 1 of 8

Employer 1

Employer 2

Employer 3

Employer 4

Employer 5

Reference 1

Reference 2

Reference 3