Application form – 365nursingandcareservices

Basic Information

All fields in this section are required

Email *

Name *

Phone *

Position Desired *

Date Available *

Full Address *

Driver's License

Do you have a valid South Australian Driver's License? *

Driver's license number *

Employment Questionnaire

Instructions

Each question is required to be answered. Answer yes or no to each question. Please fill out the optional detail field after answering each question.

Do you speak any other languages? *

If you do speak other languages, please specify *

Can you perform the essential functions and responsibilities of the position for which you are applying? *

If not, please explain: *

If yes, please explain:

Have you ever been convicted of any criminal or driving offense(s) other than a minor traffic violation? *

If yes, written documentation will be required about criminal offenses from the clerk of court about the conviction and about any driving offenses other than minor traffic violations from the motor vehicles office.

References (1 of 3)

Instructions

You must provide names of at least three professional references who have knowledge of your background and qualifications in the field you are applying for. Please give the full name, email address, and phone number

Full Name *

Email Address *

Phone *

Relationship *

References (2 of 3)

Full Name *

Email Address *

Phone *

Relationship *

Full Name (copy) *

References (3 of 3)

Instructions

You must provide at least three current reference letters and/or the name of individuals with whom a reference interview can be conducted. Please give the full name, mailing address, and phone number of three references who have knowledge of your background and qualifications the field.

Email Address *

Phone *

Relationship *

Education and Skills

If you have a degree, please specify major *

How many words per minute can you type? *

Proficient software applications

Experience (1 of 3)

Instructions

Start Date *

End Date *

Name of Employer *

May we contact your former employer? *

Full Address *

Supervisor's Name *

Phone Number *

Title and Duties Performed

Reason for Leaving

Experience (2 of 3)

Instructions

Tell us about your most recent jobs over the past 5 years. If you need more space use the notes section below the experience sections or attach a resume at the bottom.

Start Date *

End Date *

Name of Employer *

May we contact your former employer? *

Full Address *

Supervisor's Name *

Phone Number *

Title and Duties Performed

Reason for Leaving

Experience (3 of 3)

Instructions

Tell us about your most recent jobs over the past 5 years. If you need more space use the notes section below the experience sections or attach a resume at the bottom.

Start Date *

End Date *

Name of Employer *

May we contact your former employer? *

Full Address *

Supervisor's Name *

Phone Number *

Title and Duties Performed

Reason for Leaving

Experience: Additional Jobs

Tell us about any additional jobs in the past 5 years here

Sign and Submit

By submitting this form you agree

To carry out the designated responsibilities to the best of my ability. I have read the position description. I am aware there is a conditional period of 3 months prior to permanent employment. I certify that I have given true, accurate and complete information on this form to the best of my knowledge. I authorized investigation of statements made in this application and understand that false information may be grounds for denial of my position and/or dismissal if I am employed. I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge, including information provided about my residency and employment history. I also certify that I understand all questions and statements on this application.

Checkbox *

Acceptance

I HAVE READ AND UNDERSTAND THE LEGAL INFORMATION ABOVE

Understandings & Signature

You understand that 365 Nursing and Care Services will rely upon your electronic signature to the same extent as if you had signed this document in ink. If you do not understand or accept or agree to the terms and conditions set forth above, then do not submit. By entering the your name and date of birth below you signify that you understand and agree to the terms above.

Applicant's Signature File *

Click or drag a file to this area to upload.

Date *

Upload Driver License *

Click or drag a file to this area to upload.

Upload Additional Documentation (such as certifications, licenses, etc.) *

Click or drag a file to this area to upload.

I have read and accept the Employee Handbook
I have read and accept the Elder Abuse Policy