Employment Application

Orlando Lutheran Towers is an Equal Opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, age, sex, religion, national origin, disability, veteran status, citizenship status or marital status. We assure you that your opportunity with us depends solely upon your qualifications and ability to perform the job for which you are bing considered. All information on this application MUST be completed or you will NOT be considered for employment. Resumes are not accepted in lieu of completion of this application.

DO NOT PRESS ENTER DURING THIS APPLICATION -
USE THE TAB KEY TO GO BETWEEN FIELDS.

Today's Date: / /

Last Name:

First Name:

Middle Name:

Email Address: @

Address:

Apt #:

City:

State:

Zip Code:

Social Security Number: - -

Home Telephone: ( ) - Ext #

Daytime Telephone: ( ) - Ext #

Have you worked or attended school under any other names? YES NO

If YES, please give name(s):

Are you eligible for employment in the United States? YES NO

Have you ever been convicted of a crime, pled no contest, or had adjudication withheld? YES NO

If YES, please state the offense, location, date and disposition:

As a health care organization, we will do a full background check. Even expunged criminal records are accessible to us. Convictions do not necessarily prevent employment, however, failure to disclose all regarding convictions will be considered falsification of information and is grounds for refusal or dismissal if already hired.

Can you perform the essential functions of the job with or without reasonable accommodation? YES NO

EMPLOYMENT DESIRED

Position Desired:

Full-Time Part-Time Per Diem Temporary

Day Shift Evening Shift Night Shift

Expected Pay per Hour: $

Date you could begin: / /

Can you work weekends (Saturday & Sunday)? YES NO

Please list days and/or hours that you are NOT available to work:

Have you ever applied to our company before? YES NO

If YES, when?

Have you ever worked for our company before? YES NO

If YES, when?

How did you learn of this company and/or position? Orlando Sentinel Job Finder Employment Guide

Employee (Please indicate name):

Other (Please specify):

EDUCATION / TRAINING

High School Name:

High School Address:

Number of years attended:

Did you graduate or receive your GED? YES NO

GED or Graduation Date (Month/Year): /

College Name:

College Address:

Number of years attended:

Did you graduate? YES NO N/A

Graduation Date (Month/Year): /

Degree or Diploma Received:

Graduate College Name:

Graduate College Address:

Number of years attended:

Did you graduate? YES NO N/A

Graduation Date (Month/Year): /

Degree or Diploma Received:

Licenses & Certifications:

Florida RN License #:

Florida LPN License #:

Florida CNA Certificate #:

Home Health Aide Certificate

CPR Certification

Other (Please specify):

List any special skills or proficiencies such as typing, computer programs, etc.

List any language proficiencies (other than English):

REFERENCES / WORK HISTORY

Have you ever been involuntarily terminated or asked to resign? YES NO

List three references, not relatives or former employers:

Reference 1: First Name

Reference 1: Last Name

Reference 1: Occupation

Reference 1: Number of Years Known

Reference 1: Telephone ( ) - Ext #

Reference 2: First Name

Reference 2: Last Name

Reference 2: Occupation

Reference 2: Number of Years Known

Reference 2: Telephone ( ) - Ext #

Reference 3: First Name

Reference 3: Last Name

Reference 3: Occupation

Reference 3: Number of Years Known

Reference 3: Telephone ( ) - Ext #

List ALL employers during the last ten (10) years in consecutive order with present or last employer listed first. ALL INFORMATION MUST BE PROVIDED ON EACH EMPLOYER LISTED, i.e. Phone Numbers, Addresses, Dates of Employment, etc.

Name of Employer 1

Supervisor

Telephone ( ) - Ext #

Unemployed between this employer and former? YES NO

Address:

Apt #:

City:

State:

Zip Code:

Position:

Start Date: / /

End Date: / /

Starting Salary: $ Hourly Yearly

Ending Salary: $ Hourly Yearly

Reason for Leaving:

May we contact this employer? YES NO

Name of Employer 2

Supervisor

Telephone ( ) - Ext #

Unemployed between this employer and former? YES NO

Address:

Apt #:

City:

State:

Zip Code:

Position:

Start Date: / /

End Date: / /

Starting Salary: $ Hourly Yearly

Ending Salary: $ Hourly Yearly

Reason for Leaving:

May we contact this employer? YES NO

Name of Employer 3

Supervisor

Telephone ( ) - Ext #

Unemployed between this employer and former? YES NO

Address:

Apt #:

City:

State:

Zip Code:

Position:

Start Date: / /

End Date: / /

Starting Salary: $ Hourly Yearly

Ending Salary: $ Hourly Yearly

Reason for Leaving:

May we contact this employer? YES NO

Name of Employer 4

Supervisor

Telephone ( ) - Ext #

Unemployed between this employer and former? YES NO

Address:

Apt #:

City:

State:

Zip Code:

Position:

Start Date: / /

End Date: / /

Starting Salary: $ Hourly Yearly

Ending Salary: $ Hourly Yearly

Reason for Leaving:

May we contact this employer? YES NO

Name of Employer 5

Supervisor

Telephone ( ) - Ext #

Unemployed between this employer and former? YES NO

Address:

Apt #:

City:

State:

Zip Code:

Position:

Start Date: / /

End Date: / /

Starting Salary: $ Hourly Yearly

Ending Salary: $ Hourly Yearly

Reason for Leaving:

May we contact this employer? YES NO

Name of Employer 6

Supervisor

Telephone ( ) - Ext #

Unemployed between this employer and former? YES NO

Address:

Apt #:

City:

State:

Zip Code:

Position:

Start Date: / /

End Date: / /

Starting Salary: $ Hourly Yearly

Ending Salary: $ Hourly Yearly

Reason for Leaving:

May we contact this employer? YES NO

Explain Any Periods of Unemployment:

AFFIDAVIT - PLEASE READ EACH STATEMENT CAREFULLY BEFORE SUBMITTING

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I understand that Orlando Lutheran Towers is a Drug-Free Workplace as defined by Florida statute and that taking drug/alcohol tests are a condition of employment and that my refusal to take such tests when asked will disqualify me from employment consideration and if employed may result in termination. I understand that this application or subsequent employment does not create a contract of employment or guarantee employment for any definite period of time. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time, with or without cause and with or without notice. I have read, understand, and by my name and today's date typed below consent to these statements.

Full Name:

Today's Date: / /

SUBMIT APPLICATION