Employment Application Step 1 of 5 20% Personal Information* First Middle Last * Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* At which location(s) are you seeking employment? (Please specify from the list below)*Borderview Rehabilitation & Living Center, Breakwater Commons, Edgewood Rehabilitation and Living Center, Harris House, Klearview Manor, Maplecrest Rehabilitation and Living Center, Market Square Health Care Center, North Country Associates' Central Office - Lewiston, Northland Living Center, Orchard Park Rehabilitation and Living Center, Rosewood Manor, Russell Park Rehabilitation & Living Center, Sanfield Rehabilitation & Living Center, Sarah Frye Home, Southridge Rehabilitation & Living Center, Summer Commons How did you learn of this job opening?Have you ever worked for a North Country Associates' affiliated facility before?* Yes No Which Facility?*Under what name?Are you currently authorized to work in the United States?* Yes No Do you currently meet the State's healthcare worker vaccination requirements (meaning you are either vaccinated or qualify for a medical exemption)? NOTE: The COVID vaccination is no longer required; however, MMR, Varicella, and Influenza are required vaccinations. If you are granted a medical exemption, there may be specific masking requirements.* Yes No If "No", are you willing to receive the required vaccinations?* Yes No Are you seeking employment for: (please indicate all that you are willing to work)* Full Time Part Time Temporary Per Diem Shift PreferenceWhich work shift do you prefer? (IE first, second, third)Pay Expected*Please indicate the amount of pay that you expect.When will you be available to work?Please provide a specific date, or a timeframe (IE two weeks after hire, right away, other)NCA Statement & PracticesAll employment practices and procedures will be free from prejudicial discrimination. All decisions concerning hiring, firing, transferring, promotion, discipline, training, job opportunities, wage and salary levels, etc., shall be made without discrimination, in compliance with the federal and state laws. We will employ disabled individuals who are able to perform the essential duties of a position either without special accommodations or with reasonable accommodations (so long as they can be accomplished without undo hardship to the organization or its employees). EducationWhere did you attend high school & college? (Click the + button to add a new row)*School Name & AddressMajor# of Years CompletedGPADegree/Diploma Please let us know about any special training or education that you would like us to consider. (IE business college,other special courses...including military training, post graduate and nursing)Which type of work are you seeking? Please indicate your top three choices for most desired work area. (Click the + to add additional rows.) Our common work areas include: CNA,CRMA,CMT,PSS, RN,LPN, Dietary Aide, Housekeeping, Office and Administration.*Desired PositionPreference (First, Second or Third) Professional ReferencesProfessional References: Please list 3-5 people we may contact who are qualified to evaluate your capabilities. Do not include friends or family. (Click the + button to add a new row)*NameAddressOccupationTelephone Number (Students please include academic/clinical reference)If you are currently employed, may we contact your current employer?* Yes No If "No", please explain:*Have you ever been excluded from participating in any state or federal health care programs including Medicare or Medicaid?* Yes No If "Yes", please explain: Employment HistoryPlease give accurate, complete full-time and part-time employment record. Start with present or most recent employer. Please click the "+" symbol to add additional previous employers.Employment History*Company NameCompany AddressState Job Title and Describe Your WorkTelephoneStart Date (state month and year)End Date (state month and year)Reason for leaving?May we contact? This section is to be completed by Licensed Professionals and/or certifications. All others can skip by clicking "Next" at the bottom of the page.Are you currently registered, licensed or certified?* Yes No License or certification information*TypeState IssuedExpiration DateCertificate or License NumberAre there any restrictions on this license (Yes or No) Please enter all of your professional license and/or certification data here.Have you ever received a letter of concern or any form of disciplinary action against your professional license?* Yes No If "Yes", please explain:* General Information and AcknowledgementNotice to All ApplicantsFor the purpose of the following question, the definition of a crime is any act or the commission of an act that is forbidden or the omission of a duty that is commanded by a public law and that makes the offender liable to punishment by that law. Punishment may include a fine, jail/prison sentence, probation, restitution, etc. If you have been to court and/or paid a fine for an offense other than a minor traffic violation, you may likely have a criminal record. IMPORTANT: Be sure to answer this question honestly. A previous conviction may not automatically disqualify you for employment. However, should you be offered employment and this information is determined to be false or if you neglected to reveal the full details of your criminal history, the offer of employment may be rescinded. Criminal History* Yes No Have you ever been convicted of, or are you presently charged with, any crime other than minor traffic violations? ( Drunk, reckless or hit-run driving are not minor violations.)ConvictionsOffenseDate of convictionSentence If yes, please provide information regarding any current charges and/or previous convictions of any crime, other than a minor traffic violation.Acknowledgement and ConsentPlease read carefully and sign in acknowledgement If employed, this application will be made a part of your personnel record. Any misrepresentation or omission of pertinent facts will be cause for immediate dismissal. I understand that North Country Associates will conduct a criminal history background check if I accept a contingent offer of employment. I also understand that employment at North Country Associates or any of its affiliated facilities is always based on the ongoing mutual agreement of the employee and the employer. This means that employees are free to terminate the employment relationship at any time, with or without cause, and that the employer has the same privilege. I recognize that although I may be employed to work in a specific schedule, operating needs may require me to work my share of weekends, holidays, or shift rotation in order to perform work need to be completed.Please acknowledge that you have read and agree to the "Acknowledgement and Consent" above:* Yes, I have read and agree to the NCA terms of employment No, I do NOT agree to the NCA terms of employment Digital Signature:*Printing your First Name + Middle Initial + Last Name will act as your digital signature.Date MM slash DD slash YYYY Resume Upload (optional)Accepted file types: doc, docx, rtf, txt, pdf, Max. file size: 50 MB.If you have a resume you'd like to attach, please do so here. This is not required.Cover Letter (optional)Accepted file types: doc, docx, rtf, txt, pdf, Max. file size: 50 MB.Please upload your cover letter here. You may also copy and paste the contents of your cover letter in the space below. NameThis field is for validation purposes and should be left unchanged.
