* = Required Information

Personal Data

Emergency Contact Information

Job Information

RN
LPN/LVN
CNA
PCW
Companion
Other

Work Experience/Skills

Youth Services
Housing Search
MICU
Homeless
Rehab
Nursery
Employment Search
Telemetry
Psychiatry
Detox/Drug Rehab
Post Partum
Other
Homeless Shelter
GRH
Nursing Home
Rehab
Private Duty
Assisted Living / Residential Treatment

Language Skills

Spanish
French
German
Other
Full-time
Part-time
Contact
Travel
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Holidays available to work
Yes No

Certifications: List any certifications you have and expiration date

Work Experience: List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment.

Pay Rate/Salary

Yes No
Yes No
Yes No

Pay Rate/Salary

Yes No
Yes No
Yes No

Pay Rate/Salary

Yes No
Yes No
Yes No

Please list any other work related information you think would be helpful to us in considering you for employment, such as specialized training, certifications, additional work experience, etc.

Additional Information

Yes No
Yes No
Yes No
Newspaper
Trade Publication
Job Fair/Open House
Internet Site
Company Employee

I understand that I must report all accidents to my immediate supervisor and to Multicultural Care Center, LLC -- No Matter HOW SLIGHT. Yes

ACKNOWLEDGMENT (Please read carefully)

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I give Multicultural Care Center LLC permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by Multicultural Care Center LLC with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, Multicultural Care Center LLC may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release Multicultural Care Center LLC, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by Multicultural Care Center LLC, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Multicultural Care Center LLC or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Multicultural Care Center LLC, at any time, can constitute a contract of employment. No representative or agent of Multicultural Care Center LLC, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results.

I understand that Multicultural Care Center LLC is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professional’s practice. The Professional fully indemnifies Multicultural Care Center LLC against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.

I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.

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