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Thank you for your interest in St. Camillus Health Center. We are an equal opportunity employer that cares about the needs of our staff members. Please complete this application in its entirety.
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Emergency Contact Phone
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Please click Yes/No below:
If under 16 years of age, do you have a work permit?
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No
If you're not a U.S. citizen, do you have the right to work in the U.S.?
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Have you ever applied for employment at St. Camillus?
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No
Have you been previously employed by St. Camillus?
*
Yes
No
Were you referred by a St. Camillus Employee?
*
Yes
No
Name of Employee Referral
If yes, give dates and briefly describe job you performed.
Date From:
Date Format: MM slash DD slash YYYY
To:
Date Format: MM slash DD slash YYYY
Brief description of job you performed:
Reason for leaving:
Position Applying For:
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Choose One
Admissions Coordinator
Social Worker (LSW)
Certified Nursing Assistant (C.N.A.)
Registered Nurse (R.N.)
Licensed Practical Nurse (L.P.N.)
Dietary Aide
Cook
Activity Assistant
Van Driver & Housekeeper
Other
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Shift(s) you can work:
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Shift(s) you prefer to work:
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Date you can start:
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Date Format: MM slash DD slash YYYY
Type of Work
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On Call
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Click one below if completed with degree or certification:
High School or equivalent
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Last grade completed
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College
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Vocational or trade school
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Other related training?
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Last grade completed
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Reason of leaving
OK to contact?
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Company Name
Company Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
Brief job Description
Employment dates from/to
Reason of leaving
OK to contact?
Yes
No
Company Name
Company Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
Brief job Description
Employment dates from/to
Reason of leaving
OK to contact?
Yes
No
Personal References (no relatives or employers)
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Address
Phone
Name
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Phone
Name
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Phone
By submitting this form, I attest that the facts set forth in this application are true and complete. I understand that if employed, false statements on this application shall be considered sufficient cause for termination.
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