Career Inquiry Step 1 of 3 33% Name(Required) First Last Last 4 Digits of Social Security Number(Required) Phone(Required)Email(Required) Address(Required) Street Address 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 Position you are applying for?(Required)CNAPsychiatric Registered NursePsychiatric LPNMental Health TechAdministrative AssistantLPN-ERMed/Surg RN Assessment NurseMed/Surg Male AttendantMed/Surg LPNEmergency Department Travel RNEmergency Department RNUltrasound TechnologistRadiologic TechnologistSeminole Manor RN SupervisorSeminole Manor LPNSeminole Manor CNANurse ManagerStock ClerkSocial WorkerOccupational and Physical Therapy AssistantSalary Requirement(Required) Date Available to Start(Required) MM slash DD slash YYYY Willing to Travel?(Required)Choose One.YesNoWilling to Relocate?(Required)Choose One.YesNoDoes Occasional Overtime Work pose a problem for you?(Required)Choose One.YesNoDo you have adequate Transportation when called in on short notice?(Required)Choose One.YesNoAre you Legally Authorized to Work in the U.S?(Required)Choose One.YesNoHave you ever worked in this facility?(Required)Choose One.YesNoAre you related to another facility employee?(Required)Choose One.YesNoHow did you learn about this position?(Required) State Employment Commission Agency Job Listing Current Employee Internet Ad School Job Line Are you able to perform the essential, job related functions of the position you are applying for?(Required)Choose One.YesNoAre you vaccinated or have a valid medical or religious exemption from receiving a COVID-19 vaccine?(Required)Choose One.YesNoWe require all employees to be vaccinatedAre you presently charged with any violations of the law?(Required)YesNoAre you currently excluded from the participation in any federally funded healthcare program?(Required)YesNo(including Medicare and Medicaid)Education History(Required)SchoolAddressYears AttendedDegree Obtained Add RemovePlease List High School, Colleges, and and Graduate Schools, or Other Schools you attended, Use the + symbol to add a new rowProfessional References (Other than Relatives)(Required)NamePositionAddressPhoneNumber of Years Known Add RemoveGive references who have good knowledge of your work. Use the + symbol to add a new row CV or Resume Upload Drop files here or Select files Max. file size: 100 MB, Max. files: 5. Current or Most Recent JobEmployer (Company Name)(Required) Immediate Supervisor's Name(Required) Phone Number(Required) When Did you work there?(Required) Salary(Required) Your Job Title and or Duties(Required) Reason for leaving?(Required) 1st Previous JobEmployer (Company Name) Immediate Supervisor's Name Phone Number When Did you work there? Salary Your Job Title and or Duties Reason for leaving? 2nd Previous JobEmployer (Company Name) Immediate Supervisor's Name Phone Number When Did you work there? Salary Your Job Title and or Duties Reason for leaving? 3rd Previous JobEmployer (Company Name) Immediate Supervisor's Name Phone Number When Did you work there? Salary Your Job Title and or Duties Reason for leaving? AcknowledgementsHave you ever been convicted of a crime, had adjudication of a crime withheld, or pled solo contender to a crime?(Required) Yes No Have you ever been arrested for a crime, that had adjudicated?(Required) Yes No Please state the circumstances with regard to each. Please state the circumstances with regard to each. Have you ever committed a crime for which you were not arrested or convicted?(Required) Yes No Have you ever been a defendant in a civil action for intentional tort?(Required) Yes No Intentional tort commonly refers to examples, such as assault, battery, and false imprisonment.Please state the circumstances with regard to each. Please state the circumstances NOTICE REGARDING BACKGROUND INVESTIGATION(Required) I agree to the background check.Employer ("the Company") may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by Global HR Research, 27499 Riverview Center Blvd., Suite 218 Bonita Springs, FL 34134, Office: (239) 274-0048, Toll Free: 1-800-790-1205 or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report. New York applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Employer by contacting Global HR Research directly.Acknowledgement(Required) I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACTI acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Global HR Research, another outside organization acting on behalf of Employer, and/or Employer itself. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original. Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.Name(Required) First Middle Last Last 4 Digits of your Social Security Number(Required) Last 4 Digits of your Driver's License(Required) State Issued(Required)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 PacificMaiden and or Other Names used?(Required) Current Address(Required) Street Address 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 Consent(Required) I understand that by checking this box and typing my name into the field above, this document is as valid as if I have signed it.