Are you ready to join the Altenheim community? Apply using the form below.
Position
Personal Information
First Name
Middle Name
Last Name
Email Address
Present Address
Permanent Address
Main Phone homecell
Employment Desired
First Choice
Second Choice
How did you hear about this position?
Will you accept employment of: Full timePart timeTemporary
Date Available
If under 18 years old, do you have a work permit? YesNo
Education/ Training
Please include name and address of school, dates attended, courses taken, and diploma, degree, or certificate received.
High School Did you graduate? YesNo
College Did you graduate? YesNo
Lab or X-Ray Training Did you graduate? YesNo
Other Classes/ Training
Extracurricular Activities While in School
Areas of Specialization or Major Interest
Other Relevant Qualifications (honors, volunteer work, organization memberships, etc.)
Professional Licenses/ Certifications
Please include license type, organization or state issued, date issued, and number if applicable.
License/ Certification 1
License/ Certification 2
License/ Certification 3
Military Record
Please include branch, entry rank, separation rank, separation date, and military occupational specialty.
Specialized Training
List Service Awards, Commendations
Employment History
List current (or most recent) employer first and all others in reverse chronological order.
Position 1 Company Name Address Phone Position Title Immediate Supervisor's Name and Title Dates Employed to Job Description and Responsibilities May we contact for a reference? YesNo
Position 2 Company Name Address Phone Position Title Immediate Supervisor's Name and Title Dates Employed to Job Description and Responsibilities May we contact for a reference? YesNo
Position 3 Company Name Address Phone Position Title Immediate Supervisor's Name and Title Dates Employed to Job Description and Responsibilities May we contact for a reference? YesNo
Position 4 Company Name Address Phone Position Title Immediate Supervisor's Name and Title Dates Employed to Job Description and Responsibilities May we contact for a reference? YesNo
Position 5 Company Name Address Phone Position Title Immediate Supervisor's Name and Title Dates Employed to Job Description and Responsibilities May we contact for a reference? YesNo
Use this space to give us further information which may assist us in placing you.
References
List three references who are not relatives or former employers. Please include name and relationship, title, company name and address, and a contact phone number.
Reference 1 Reference 2 Reference 3
Availability Information
Please indicate what hours you are available to work each day. If none, write "Not Available".
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Primary Position Desired Will you accept another position? YesNo If so, what?
Are you available to work: Weekends YesNo Rotating Shifts YesNo Holidays YesNo On Call YesNo
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 the Administrator of this institution. I also understand that typing my name in the box below serves as my digital signature.
If your availability status changes, it is your responsibility to notify your department head or the Administrator. Such changes will be effective, then, for any future employment.
This institution does not discriminate 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 the ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.
I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility such persons, companies, or corporations supplying such information. I consent to take the physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates 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 this application form.
If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.
