Employment Application Form

APPLICANT INFORMATION

First Name *

Last Name *

M.I.

Date

Street Address

Apartment/Unit #

City *

State

ZIP

Phone Number *

E-mail Address *

Date Available

Desired Salary

Position Applied for

Are you a citizen of Nigeria?
Yes No

Have you ever worked for this company?
Yes No

Have you ever been convicted of a felony?
Yes No

Attach Resume

EDUCATION

High School

Address

From

To

Did you graduate?

Yes

No

Degree

College

Address

From

To

Did you graduate?

Yes

No

Degree

Other

Address

From

To

Did you graduate?

Yes

No

Degree

REFERENCES

Please list three professional references.

Full Name

Relationship

Company

Phone

Address

Full Name

Relationship

Company

Phone

Address

Full Name

Relationship

Company

Phone

Address

PREVIOUS EMPLOYMENT

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

May we contact your previous supervisor for a reference?

Yes

No

From

To

Responsibilities

Reason for Leaving

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

May we contact your previous supervisor for a reference?

Yes

No

From

To

Responsibilities

Reason for Leaving

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

May we contact your previous supervisor for a reference?

Yes

No

From

To

Responsibilities

Reason for Leaving

MILITARY SERVICE

Branch

From

To

Rank at Discharge

Type of Discharge

If other than honorable, explain

NEXT OF KIN

Last Name

First Name

M.I.

Street Address

Apartment/Unit #

City *

State

ZIP

Hours Desired

Full Time	Part-Time
On call	All

Shifts Available

Days (Theory)	Days (Clinical)
All

PROFESSIONAL LICENSURE

Type

Number

Type

Number

Expiration

Current States

Expiration

Current States

APPLICANT DECLARATION

Are you 16 or older?

Yes

No

Have you ever been disciplined by professional or state ethics or licensing board?

Yes

No

If yes, please explain

HANDICAPPED

Investigation required by local, state, or federal laws. I understand that if I am hired by Adonis School of Nursing my employment will be for an indefinite period of time and will be "at will" which means that either Adonis School of Nursing or I may terminate the employment relationship at anytime and for any reason or no reason.

I further understand that, if hired, my at-will employment status may only be changed in written contract signed by the management of Adonis School of Nursing and that no representative of Adonis School of Nursing has the authority to make oral promise to me concerning my employment. Finally, I also understand that Adonis School of Nursing may adopt, from time to time, policies or handbooks dealing with benefits and other terms or conditions of employment. These policies or handbooks do not constitute a contract of employment between Adonis School of Nursing and me. Adonis School of Nursing reserves the right to change or discontinue these policies and / or handbooks at any time with or without notice to me Adonis School of Nursing strives to provide a safe, healthy and productive work environment and supports a smoke free, alcohol-free work environment.

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Name *

Date

Sun	Mon
Tues	Wed
Thu	Fri
Sat