Apply | Elcor Nursing and Rehabilitation Center

You may use this Application for Employment form to apply for any job.

Position(s) applied for:
2nd Choice
How did you learn about us?*
How did you learn about us?*
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Social Security Number*
Email*
Desired Salary*
per hour per week
If you are under 18 years of age, can you provide required proof of your eligibility to work?*
- Yes
- No
Have you ever filed an application with us before?*
- Yes
- No
If yes, give date
Have you ever been employed with us before?*
- Yes
- No
If yes, give date
Are you currently employed?*
- Yes
- No
If yes, name of present employer:
May we contact your present employer?*
- Yes
- No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?*
- Yes
- No
(Proof of citizenship or immigration status will be required if offered employment.)
Do you have transportation?*
- Yes
- No
Have you ever been convicted of a violation of the law?*
- Yes
- No
(A conviction may be relevant if job-related, but does not necessarily disqualify anyone from employment.)
If yes, please list and describe all convictions:
When are you available to work?*
- Full Time
- Part Time
- Temporary
- On Call
- 1st Shift
- 2nd Shift
- 3rd Shift
- Anytime
On what date would you be available to work?*
Education
Middle School Name & Location
Middle School Grades Completed:
- 5
- 6
- 7
- 8
Middle School Diploma/Degree
Describe Middle School course of study
High School Name & Location*
High School Grades Completed:*
- 9
- 10
- 11
- 12
High School Diploma/Degree*
Describe High School course of study
College/University Name & Location*
College/University Years Completed:*
- 1
- 2
- 3
- 4
College/University Diploma/Degree
Describe College/University course of study
Describe any specialized training, course work, additional degrees, apprenticeships, skills and extra-curricular activities which may assist you in the position for which you have applied:
Professional Licenses and/or Certifications
Type State Issued Date Number
Nurse Applicants: Date of original licensure in New York
MM slash DD slash YYYY
Any other names, such as maiden names and former married names, by which they you been known?
Employment Record
Start with the most current employer and include U.S. Military Service.
Employer*
Employed From*
MM slash DD slash YYYY
Employed Until*
MM slash DD slash YYYY
Firm*
Address*
Position held*
Phone Number*
Supervisor's name*
Reason for leaving/Reason for job search:*
Job duties:*
Employer
Employed From
MM slash DD slash YYYY
Employed Until
MM slash DD slash YYYY
Firm
Address
Position held
Phone Number
Supervisor's name
Reason for leaving/Reason for job search:
Job duties:
Employer
Employed From
MM slash DD slash YYYY
Employed Until
MM slash DD slash YYYY
Firm
Address
Position held
Phone Number
Supervisor's name
Reason for leaving/Reason for job search:
Job duties:
Employer
Employed From
MM slash DD slash YYYY
Employed Until
MM slash DD slash YYYY
Firm
Address
Position held
Phone Number
Supervisor's name
Reason for leaving/Reason for job search:
Job duties:
First Applicant’s References*
Name of Reference Phone No. Address Relationship
Second Applicant’s References*
Name of Reference Phone No. Address Relationship
Third Applicant’s References*
Name of Reference Phone No. Address Relationship
Are you related to or do you know anyone who is or was employed by Elcor? If so, please list names and relationships.
Name Relationship
Please state any other names, such as maiden names and former married names, by which you have been known:*

(If no previous names, please write “None")
Applicant Authorization:
I voluntarily give Elcor the right to make a thorough investigation of my past employment, military duty, references and convictions. I agree to cooperate in such investigation and release from all liability or responsibility all persons, companies, schools, organizations, agencies or corporations supplying such information. This information may include verification of employment dates, salary, as well as performance evaluations, reason for termination, eligibility for rehire, attendance record and conviction record. This authorization includes any organizations and/or persons with which I have an affiliation as named above. I also do hereby state that I have never been discharged by an employer for patient/child negligence or abuse. Further, I have never been found guilty of patient/child negligence or abuse in any situation. I certify that answers given herein are true and complete. I authorize investigation of all statements contained in this application for employment and copies of this application as may be necessary in arriving at an employment decision.
Signature*
Date*
MM slash DD slash YYYY

Elcor Nursing & Rehabilitation Center provides equal employment opportunities to all individuals based upon their qualifications and experience. We prohibit discrimination based on race, color, religion, sex, age, national origin, sexual orientation, gender identity, veteran status, handicap or any other protected characteristic as established by law.

Type	State Issued	Date	Number

Name	Relationship

Education

Employment Record

Applicant Authorization: