Employment Opportunities General Employment Application Job Application Date Which position is of interest? * CNA RN LPN Environmental Services Recreational Services Dietary Services Other Shifts Personal Information Name * First Last * Last Email * Home Phone Mobile Phone Address * City State/Province Zip/Postal Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Country Employment Information What other position(s) would you consider? Desired salary: Would you work other than shift indicated? Yes No Which are you interested in? Full Time Part Time Per Diem If Part Time or Per Diem, how many hours are you available? Are you available to work the following: Weekends Holidays Indicate day(s) / hour(s) you are not available or prefer not to work: Date available to start work: Are you over the age of 18 years? Yes No (A)Have you ever been convicted of a felony? Yes No (B)Have you ever been convicted of cruelty to persons? Yes No (C)Have you ever been convicted of assault of victim 60 years or older? Yes No If you answered "Yes" to (A) (B) or (C), please describe the nature of the offense, the date & place of conviction, and the underlying circumstances or any other information that may help to evaluate your eligibility for employment: (D) Have you ever been subject to disciplinary actions by a Health Care licensing agency in any state, the District of Columbia, a United States possession or territory, or a foreign jurisdiction? Yes No If "Yes" to (D), please describe the nature of the offence, the date & action of the HealthCare licensing agency involved* (a record of disciplinary action by a licensing agency will not necessarily disqualify you from employment): Do you have relatives who are presently (or formerly) employed by The Curtis Home? Yes No If yes, who? How were you referred to The Curtis Home: Do you speak any languages which may be helpful in performing the job for which you are applying for: Yes No If yes, what langauge? High School Education: Name / Location / Course or Major / Years Completed / Degree: College Education: Name / Location / Course or Major / Years Completed / Degree: Graduate School Education: Name / Location / Course or Major / Years Completed / Degree: Technical Training Education: Name / Location / Course or Major / Years Completed / Degree: Please list any other certifications or special skills that you have that may benefit you in the position for which you are applying:
