Job Application

Personal Information

Welcome to the Bolster & Jeffries Career Advancement Area

To be considered for employment with one of the Bolster and Jeffries facilities please fill out the online application below. Please be sure to fill in each blank with information or n/a if the blank doesn't apply.

Which facility are you applying to? Hearthstone Place Auburn Healthcare Last Name* First Name* M.I. Street* City* State* Zip Code* Phone* Other Phone Email*

Employment Desired

First Choice*

Shift*

Salary/hr

Second Choice

Shift

Salary/hr

Third Choice

Shift

Salary/hr

Preferred Employment Types* Full Time
Part Time
Temporary

How did you learn of this opening?

Education

Education Summary

Highest Grade Level Completed:

Scholastic Honors Received:

Extracurricular Activities While In School:

Number of Professional Organizations

Honors and Experience

Honors Received

Volunteer Experience

Community Service Experience

Did you serve in the Armed Forces?

If so, what branch?

Dates of Duty (From,To)

Rank At Discharge

Schools Attended

Grammar/Grade School*

Location (City, State)*

Courses Taken

Completed

High School

Location (City, State)

Courses Taken

Completed

College

Location (City, State)

Courses Taken

Completed

Vocational / Business

Location (City, State)

Courses Taken

Completed

Professional Education

Location (City, State)

Courses Taken

Completed

Laboratory or X-Ray Training

Location (City, State)

Courses Taken

Completed

Professional Licenses and/or Certifications

Type

Organization / State Issued

Date Issued

Number

Type

Organization / State Issued

Date Issued

Number

Type

Organization / State Issued

Date Issued

Number

Type

Organization / State Issued

Date Issued

Number

If your former employment references, education or military service are under another name other than indicated on the application, please indicate here:

Employment Record

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

By clicking on the "Submit" button below I voluntarily give this institution the right to make thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination, and this institution at such times may require such future physical examinations as and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which related to the essential duties I would be required to perform.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on the application form.

If employed, I will be required to complete any employment verification form (i-9), and within three days show satisfactory evidence of identity and eligibility for employment.

Employer 1

Name

Address

City

State

Zip Code

Supervisor

Phone

Hire date

Last date

Start wage

End wage

Positions and Duties

Employer 2

Name

Address

City

State

Zip Code

Supervisor

Phone

Hire date

Last date

Start wage

End wage

Positions and Duties

Employer 3

Name

Address

City

State

Zip Code

Supervisor

Phone

Hire date

Last date

Start wage

End wage

Positions and Duties

Employer 4

Name

Address

City

State

Zip Code

Supervisor

Phone

Hire date

Last date

Start wage

End wage

Positions and Duties

Employer 5

Name

Address

City

State

Zip Code

Supervisor

Phone

Hire date

Last date

Start wage

End wage

Positions and Duties

Employer 6

Name

Address

City

State

Zip Code

Supervisor

Phone

Hire date

Last date

Start wage

End wage

Positions and Duties

Have you ever been convicted of a crime? If Yes, what, when and where? (Conviction of a criminal offense will not necessarily preclude your employment.) Please use this space to give further information that will assist us is placing you, including two personal references not related to you, whom you have know for at least one year.

Availability Record

Please indicate days and hours you are available to work. Please, be specific.

Sunday (From, To)

Monday (From, To)

Tuesday (From, To)

Wednesday (From, To)

Thursday (From, To)

Friday (From, To)

Saturday (From, To)

Further Availability

IF YOUR AVAILABILITY CHANGES, IT IS YOUR RESPONSIBILITY TO FILL IN AN "AVAILABILITY CARD" INDICATING THE CHANGES. SUCH CHANGES WILL BE EFFECTIVE, THEN, FOR ANY FUTURE EMPLOYMENT.

By pressing the "Submit" button below I understand that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as directed by my department head or administrator of the institution.

FOR THIS TYPE OF EMPLOYMENT, STATE LAW REQUIRES A CRIMINAL RECORD CHECK AS A CONDITION OF EMPLOYMENT.

Primary Position Desired

Will you accept another position?

If so, what?

Are you available to work weekends?

Are you available to work holidays?

Are you available to work rotating shifts?

Do you limit your annual earnings due to social security or other reasons?

If yes, please state the maximum amount you wish to earn.

Please enter the letters and/or numbers shown.

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