Name*

Current Mailing / Street Address*

Social Security Number* Last 4 Digits Only

E-mail Address*

Primary Phone Number*

Secondary Phone Number

List any other names by which you have been known (including nicknames):

Are you over the age of 18?*

Yes

Are you a U.S. Citizen or legally authorized to work in the United States?*

Yes

Position(s) applying for:*

Rate of pay expected:*

Are you currently employed?*

Yes

If yes, may we inquire of your present employer?*

Yes

Would you work full time or part time?*

Full Time

Part Time

Please specify days and hours you are available to work:*

Did Syracuse Home previously employ you?*

Yes

If yes, when?

Have you ever been found guilty of patient / resident abuse or convicted for a crime or violation other than a traffic violation?*

Yes

If yes, please explain. If no, type "N/A".*

Do you have any charges pending as described above?*

Yes

If yes, please explain. If no, type "N/A".* Affirmative answers to the above questions will not necessarily disqualify you for employment.

If your application is considered favorably, on what date will you be available to work?*

Please state why you feel you are qualified for this position:*

Referred by:

EDUCATION

HIGH SCHOOL

School Name

Last Year Completed

Do you have a high school diploma or equivalent?

Yes

FURTHER EDUCATION OR CERTIFICATES

School Name

Course of Study

Last Year Completed

Did you graduate?

Yes

Diploma or Certification Received:

EMPLOYMENT HISTORY

Include three jobs and begin with your present or last job. If you do not have three previous jobs or employers, only fill out one or two of the sections. If you have no previous job experience, click "no" for the question below. Include any military service and volunteer activities. Exclude groups which indicate race, color, religion, sex, age, or natural origin.

For each previous employer listed, a Reference Release form must be submitted. You can access the form by clicking here.

Do you have previous job experience?*

Yes

EMPLOYER #1

Employer Name

Employer Address

Employer Telephone

Job Title

Job Duties

Dates Employed Start Date / End Date

Immediate Supervisor Name

Immediate Supervisor E-mail

Reason(s) for leaving:

Have you completed the required Reference Release form for this employer? You can access the form by clicking here.

EMPLOYER #2

Employer Name

Employer Address

Employer Telephone

Job Title

Job Duties

Dates Employed Start Date / End Date

Immediate Supervisor Name

Immediate Supervisor E-mail

Reason(s) for leaving:

Have you completed the required Reference Release form for this employer? You can access the form by clicking here.

EMPLOYER #3

Employer Name

Employer Address

Employer Telephone

Job Title

Job Duties

Dates Employed Start Date / End Date

Immediate Supervisor Name

Immediate Supervisor E-mail

Reason(s) for leaving:

Have you completed the required Reference Release form for this employer? You can access the form by clicking here.

PERSONAL REFERENCES

Please give names of persons not related to you.

REFERENCE #1

Include name, address, phone number, occupation, and years known.*

REFERENCE #2

Include name, address, phone number, occupation, and years known.*

REFERENCE #3

Include name, address, phone number, occupation, and years known.*

PLEASE READ AND SIGN BELOW

I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that, if employed, falsified statements contained on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and these references listed above to give you any and all information they may have, personal or otherwise. I release all parties from liability for any damage that may result from furnishing the same to you. I understand and agree that, if hired, my employment is for no definite period, and may, regardless of the date of payment of wage or salary, be terminated at any time without any period of notice.*

Reset