Lower Umpqua Hospital - Application Information

Aidan Senior Living at Reedsport

An Equal Opportunity Employer

Application for Employment

(PLEASE PRINT CLEARLY)

Date ________

PERSONAL INFORMATION

1. Full legal name
		Last First Middle
2. Address
	Street City State Zip Code
3. Home Phone			4. Social Security Number

5. If you are under the age of 18, do you have a work permit? Yes No N/A

6. E-mail Address

EMPLOYMENT DESIRED
7. Position applied for:

8. Shift you prefer: Day Evening Nights 9. Hours desired: Full-time Part-time

10. How did you hear of this opening?

11. Date you can start:

12. Have you ever worked for this company before? Yes No

13. If so, when:					14. Supervisor:

15. Reason for leaving:

EDUCATION
16. Highest grade completed (circle or write):		1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4
	Grade School High School College
17. Name and location of last school attended:

18. Vocational or trade training:

19. Extracurricular activities while in school:

20. Area of specialization:

WORK EXPERIENCE

List below your work experience, starting with your most recent employment.

Dates Employed	Name & Address of Employer	Supervisor	Phone	Reason for Leaving

REFERENCES

List persons who know you well. Do not include relatives or former employers.

Name	Address	Phone	Years Acquainted

I hereby certify that all entries on both sides and attachments are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any employment with Aidan Senior Living at Reedsport. I understand that all information on this application is subject to verification and I consent to a criminal history background check. I also consent to references from former employers and educational institutions listed regarding this application.

Applicant’s Signature____________________________________________ Date____________________

Begin a Career at Aidan Senior Living

Please begin the application process by reading the following: