onlineempappform

Online Employment Application

Question? Comment? Contact our Marketing Director or Webmaster

Please check below all companies for which you wish to be considered for employment: *
Chicora Medical Center, Chicora, PA
Countryside, Mercer, PA
Emlenton's Laurel Manor, Emlenton, PA
Fair Winds Manor, Sarver, PA
South Fayette Nursing Center, Markleysburg, PA
Sugar Creek Rest/ Meadow Lake Manor, Worthington, PA
Trinity Living Center, Grove City, PA

Other Quality Life Services Companies
Quality Life Services (Corporate), Butler, PA
Quality Pharmacy, Chicora, PA
Pine Tree Village Apartments, West Middlesex, PA
Newberry Apartments, Grove City, PA
Sugar Creek Health Management, Butler, PA

General Information

Name (Last, First, Middle) : *
Address:
City:
State:
Zip Code:
Email: *
Phone:
How many years have you lived at the above address?
Have you lived outside of the state of PA within the past 2 years?	Yes No
Previous address (Addr, City, State, Zip):
Lived at previous address how long?
Professional License #:
What type of licence is this:
Specify type of work interested in:
If other, please fill in:
What type of employment are you interested in?
If you desire full time employment, would you be willing to start part-time and move to full-time?	Yes No
If part-time, please list days and hours:
When will you be available for employment (date)?
Please indicate what shifts you are available/ willing to work: (check all that apply)	Morning/ Afternoon Afternoon/ Evening Night
Are you willing to work overtime?	Yes No
Have you ever been employed by this facility?	Yes No
If yes, please list dates, and reason for leaving:
List any relatives or acquaintances employed by this facility:
Would you be willing to work two out of three weekends?	Yes No NA
Are you willing to work for �call-offs�?	Yes No

Education

Type of School	Name of School	Major Field of Study	# Years Attended	Graduate?
Elementary
High School
College/ Univ.
Trade/ Business
Other

Record

Other names you may have been employed under?

Name & Address of Employer (most recent 1st)	Employer Phone Number	Ending Salary	Date Employed	Date Ended

Job Title
Duties

Job Title
Duties

Job Title
Duties
May we contact the employers listed above?			Yes No
If not, please indicate which employer(s) you do not wish us to contact:
List other work experience and/ or skills, knowledge, talents, business license or other related experience not covered elsewhere:
Additional comments you feel would be important in our consideration of your application (such as hobbies, or other honors):

Character References

Please list people who know you well, not including relatives or employers.

Name	Occupation	Address	Yrs. Known	Phone #

Note To All Applicants: The applicant hereby authorizes this company to check all references and it is understood that false statements on the application may be considered sufficient cause for dismissal. Filing of this application does not indicate there are any positions open and does not in any way obligate this company.

Nursing and Personal Care Home Applicants Only: I do verify that I have never been convicted by court of law, or committed of any act of abusing, neglecting or mistreating an elderly individual, physically, verbally or financially. I do also verify that I have never been found guilty of abusing, neglecting or mistreating a nursing home or personal care resident by any State Nurse's Aide Registry or Licensing Authority. If at any time during my employment this statement is found to have been untrue, I understand it will result in immediate termination of employment.

By clicking the "Send Application" button below, I verify that all the below information is true, complete, and correct to the best of my knowledge.

What led you to fill out this online application?
Comment :

�2007 Quality Life Services | Website developed by WSI