Employment Application

Employment Application

Personal Information
Are you available to work(Required)
Are you eligible to work in the U.S?(Required)
Are you at least 18 years of age or older?(Required)
(If no, you may be required to provide authorization to work.)
Referral Source
Have you worked at our company before?
Do you know anyone who works at our company?


To help us consider you for a position that matches your availability, please list the times you would be able to work.
Days available for work:
Are you available to work nights?

Educational Background

Name and locations of educational centers and programs.

Employment History

Include your last seven (7) years of employment history, including periods of unemployment, starting with the most recent and working backwards in time. (Mark "N/A" if not applicable.)
MM slash DD slash YYYY
MM slash DD slash YYYY

MM slash DD slash YYYY
MM slash DD slash YYYY

MM slash DD slash YYYY
MM slash DD slash YYYY
Did you work for any of these employers under a different name?(Required)

Personal References

Give the names of three persons not related to you, whom you have known at least three (3) years.

Applicant's Statement

Disclosure, acknowledgement and authorization to release information

As part of the application process for employment at Holiday Health Care, I understand that they and/or their agents may conduct an investigation of my personal information. The investigation might include, but is not limited to: Names and dates of previous/current employment Work experience and history Worker’s compensation history and claims Criminal history records from state, federal and other agencies Education history

Drug and substance abuse disclosure and acknowledgement

It is our company’s policy and commitment to maintain an alcohol/drug free work place and that the company, unless prohibited by state law, may require drug screening tests as part of its selection and hiring process. I understand that such drug screening may consist of the testing of a urine sample or other medically recognized test designed to detect traceable amounts of controlled substance in my body. If any detectable amounts are found in my body, a second test, approved by the NIDA will be performed. If the results on the second test are also positive, I will be disqualified from consideration for employment and any offer of employment will be withdrawn. I further understand and agree that if I am employed, I may be required to submit to alcohol/drug testing under certain circumstance during my employment.

Disclosure of employment relationship and acknowledgement

I understand that this employment application and any other documents, including policies, handbooks, guidelines, practices, benefits or manuals, are not intended to create any contractual obligation which in any way conflicts with Holiday Health Care policy. I also understand that the employment relationship between the Company and each employee is at-will and can be terminated, with or without cause, and with or without notice at any time, at the option of either the Company or the employee. I further understand that any oral or written statements to the contrary are expressly disavowed and should not and cannot be relied upon. Exceptions to this policy may only be made with the prior written approval of the President of the Company. Holiday Health Care reserves the right to make changes to its policies, practices, guidelines, handbooks, manuals, or benefits when, in its sole judgment, it deems necessary or useful to do so. I certify the information provided in this application is true and complete to the best of my knowledge and understand that falsification of any information is grounds for rejection of my application or termination of employment if you employ me. I understand that this information form is good only for sixty (60) days from today’s date. If I still desire a position with the company after this date expires, it will be my responsibility to fill out a new form and file it with the company. Otherwise, the company will not consider me for employment after this date expires. I understand that I may be required to pass a physical examination to determine if I am able to meet the required performance and health standards specific to the position for which I am applying. I understand that any offer of employment is contingent upon the satisfactory outcome of all required information, background checks, testing and physical examination as listed above.

I attest that I have read and understand the duties and requirements of the position for which I am applying. I attest that I am capable of performing the essential functions and duties of the position for which I am applying with or without reasonable accommodation.

An Equal Opportunity Employer - All qualified applicants will receive consideration for employment without regard to race, color, age, religion, ancestry, sex, sexual orientation, national origin, citizenship status, disability status, protected veteran status, or any other characteristic protected by law.
Acknowledgement of Applicant's Statement(Required)
This field is for validation purposes and should be left unchanged.