Employer Name 3:

Address:

Telephone:

Date Employed From and To:

Title and Duties:



Starting Position and Final Position:

Supervisor's Name and Title:

Reason For Leaving:

Base Salary:


May we contact employers listed above?

If No, indicate by number which employer(s)
you do not wish us to contact:

Have you ever been disciplined or fired?

If Yes, please explain:


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Digital Employment Application
For more information, call 570-297-4111
Full Name(first, middle, last):

Address(street, city, state, zip):

Date of Application:

Email:

Telephone or Number where you can be reached:

Social Security Number:

Have you ever lived in a state other than
Pennsylvania in the last two years?

If so, name the state or states:

Are you 18 years of age or older?
If No, hire is subject to verification that
you are a minimum legal age.

If hired, can you provide the documents required
to prove that you are authorized to work in the U.S.?

Please provide any additional information we need about your name to verify your employment/education record.

Military Experience

Branch

Years of Service

Rate or Rank

Type of Discharge​

It is the policy of Bradford County Manor to consider all applicants for employment without regard to age, race, color, national origin, sex, ancestry, religion, or handicap; also affirmative action will be taken to employ and advance in employment qualified handicapped individuals who, with reasonable accommodation, can perform the functions of a job. 

Please complete thoroughly before submitting.
Since the age of 18, have you ever been convicted of a felony or misdemeanor?

Position Applied for:

How did you learn of this employment opportunity?

Have you ever been employed by this facility
or Bradford County?

If yes, where:

Are you interested in Full Time, Part Time, Occasional?
(please check all that apply)

What is your shift preference?

If your position includes rotating shifts, including weekends and holidays, are you available for the position?

Date available for employment:

Salary Desired $

High School:

High School Address:

Did You Graduate:

Course or Major:


College or University:

College/University Address:

Degree:

Course or Major:


Other:

Other Address:

Degree:

Course or Major:


Nurse Aide Training Course:

NATC Location:

How many hours completed?

Are you certified?​
State:

Number:

State:

Year Received:

Expiration Date:


State:

Number:

State:

Year Received:

Expiration Date:

Education
Professional Registration(s), License(s)
Employment History
Employer Name 1:

Address:

Telephone:

Date Employed From and To:

Title and Duties:



Starting Position and Final Position:

Supervisor's Name and Title:

Reason For Leaving:

Base Salary:
Employer Name 2:

Address:

Telephone:

Date Employed From and To:

Title and Duties:



Starting Position and Final Position:

Supervisor's Name and Title:

Reason For Leaving:

Base Salary:
References | List 3 persons, not relatives or former supervisors.
Reference 1
Name, Address, Telephone, Occupation, Years Known



Reference 2
Name, Address, Telephone, Occupation, Years Known



Reference 3
Name, Address, Telephone, Occupation, Years Known

I certify that the information submitted by me in this application and during any personal interview is true and complete to the best of my knowledge.  I understand that any false information provided in this application or during any personal interview shall be considered sufficient cause for denial of my application or, if I am employed, for termination of employment.  I hereby authorize you to make any investigation of any information provided on this application unless noted otherwise.  I understand that all information released will be held in strict confidence and I hereby release Bradford County Manor and the previous employer, school, and/or personal references from any liability for damages resulting directly or indirectly from such disclosures.  I understand that my employment is contingent upon receipt of a current physical exam, drug and alcohol test and Mantoux test.  I also understand that, should I become employed by this facility, my employment and compensation can be terminated with or without cause, at any time, at the option of either this facility or myself.  I further understand that if employed, my employment shall not be treated as a contractual relationship.  I agree employed as the may exist and be amended from time to time.
*Signature (Full Name):

Date:
Signature
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
Full
Part
Occ.
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO