*First Name:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Day Phone:
Evening Phone:
Cell Phone:
Email Address:
*Are you?
United States Citizen
a national of the United States
an alien lawfully admitted for permanent residence
an alien authorized to be hired for employment for which you are applying
*Birth Date:
POSITION DESIRED
RN Supervisor
If your application is considered favorably, on what date will you be available for work?
*Were you previously employed by the Rouse Estate?
Yes
No
If yes, Dates: What Department?
EDUCATION AND TRAINING
High School
College
Trade/Tech School
EMPLOYMENT HISTORY
Please list your most recent employer
*Employer: Full Time Part Time
Employer Address:
*Dates of Employment: From: To:
Starting Salary/Pay: Final Salary/Pay:
Immediate Supervisor: Phone Number:
Position Title: Reason for Leaving:
Give a brief description of work performed:
GENERAL INFORMATION
*Have you been a resident of Pennsylvania for at least the last 2 years?
Yes
No
*Have you ever been convicted of a felony?
Yes
No
If yes, please charge count and date:
*Have you ever been dismissed from employment due to abuse of clients and/or residents?
Yes
No
If yes, please explain:
COMMENTS
Please provide us with any comments in the section below
RESUME
If you have a resume that you would like to include with your application, please attach it below.
Resume:
TERMS AND CONDITIONS
"I certify that the information contained in this application is correct to the best of my knowledge and understand that falsification of this information is grounds for refusal to hire or, if hired, dismissal. I authorize any of the persons or organizations referenced to in this application to give you and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application and release all such information. In consideration of my employment and my being considered for employment by The Rouse Estate, I agree to conform to the rules and regulations of The Rouse Estate, "including consent to the hours of work scheduled by The Rouse Estate under the Fair Labor Standards Act" and acknowledge that these rules and regulations may be changed, interpreted, withdrawn, or added to by The Rouse Estate at any time, at The Rouse Estate's sole option and without any prior notice to me. I further acknowledge that my employment may be terminated, and any offer of employment, if such is made, may be withdrawn, with or without cause, and with or without proper notice, at any time, at the option of The Rouse Estate or myself. I understand that no representative of The Rouse Estate has any authority to enter into any agreement for employment for any specified period of time, or assure to make some other personnel move, either prior to commencement of employment or after I have become employed, or to assure any benefits or terms and conditions of employment or after I have become employed, or to assure any benefits or terms and conditions of employment, or make any agreement contrary to the foregoing. I understand that an offer of employment is contingent upon satisfactory completion of an employment physical examination which shall be considered only in compliance with the Federal Rehabilitation Act, the Americans With Disabilities Act, and the Pennsylvania Human Relations act, and that any information received from such an examination shall be considered by the employer to be a confidential medical record and treated as such. I further understand that, if employed, I will be subject to an initial evaluation period during which I may be terminated without notice. I acknowledge that I have been advised that this application will remain active for no more than twelve months from the date it was made."
*I have read and understand the above terms and conditions
