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Employment Application

Please choose the position that you are applying for from the drop down menu:
Required
Contact Information
First Name *
Last Name *
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Are you 16 years of age or older?
Have you ever been convicted, reprimanded, or disciplined for mistreatment, neglect or abuse of residents/patients or misappropriation of their property?
Have you ever had a finding by an agency or institution against you for child abuse or neglect?
If hired, can you furnish proof that you are eligible to work in the United States?
Are you aware of the job related functions for the job for which you are applying? (Note accompanying job description)
Have you ever worked as a certified nurses aide?
Shift(s) you can work (check all that apply)
Have you ever applied at Nelson County Health System before?
Have you ever worked at Nelson County Health System before?
Education: if the job for which you are applying has educational or training requirements, please complete the following according to requirements in the job description.
Highest grade completed
Month
/
Day
/
Year
Month
/
Day
/
Year
Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with us?
References: List 3 persons not related to you.
First Name *
Last Name *
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
First Name *
Last Name *
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
First Name *
Last Name *
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Former Employers: List below your work experience, starting with your present or latest employment.
1) Former Employer
Country
Address Line 1
Address Line 2
City
State/Province
Postal Code
First Name
Last Name
May we contact this employer for a reference?
2) Former Employer
Country
Address Line 1
Address Line 2
City
State/Province
Postal Code
First Name
Last Name
May we contact this employer for a reference?
3) Former Employer
Country
Address Line 1
Address Line 2
City
State/Province
Postal Code
First Name
Last Name
May we contact this employer for a reference?
Please read and check each paragraph, then sign below.
I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure employment can be grounds for rejection of application or, if I am employed by Nelson County Health System, terms for my immediate expulsion from Nelson County Health System.
I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or Nelson County Health System.
I permit Nelson County Health System to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release Nelson County Health System, my former employers, and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.
Please type full name for a Signature:
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