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* 1st 2nd 3rd P.R.N. No preference Salary/hr Second Choice Shift 1st 2nd 3rd P.R.N. No preference Salary/hr Third Choice Shift 1st 2nd 3rd P.R.N. No preference Salary/hr Preferred Employment Types* Full Time Part Time Temporary How did you learn of this opening? Education Education Summary Highest Grade Level Completed: 8 9 10 11 12 13 14 15 16 Less than 8 Scholastic Honors Received: Extracurricular Activities While In School: Number of Professional Organizations None 1 2 3 4 5 Honors and Experience Honors Received Volunteer Experience Community Service Experience Did you serve in the Armed Forces? None Yes No If so, what branch? None Army Navy Airforce Marines Dates of Duty (From,To) Rank At Discharge Schools Attended Grammar/Grade School* Location (City, State)* Courses Taken Completed None Yes No High School Location (City, State) Courses Taken Completed None Yes No College Location (City, State) Courses Taken Completed None Yes No Vocational / Business Location (City, State) Courses Taken Completed None Yes No Professional Education Location (City, State) Courses Taken Completed None Yes No Laboratory or X-Ray Training Location (City, State) Courses Taken Completed None Yes No 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? None Yes No If so, what? Are you available to work weekends? None Yes No Are you available to work holidays? None Yes No Are you available to work rotating shifts? None Yes No Do you limit your annual earnings due to social security or other reasons? None Yes No If yes, please state the maximum amount you wish to earn. Please enter the letters and/or numbers shown. reset submit Thank you for submitting your application! Please turn on javascript to submit your data. Thank you! Made with BreezingForms for Joomla!® by Crosstec