THE GOOD SAMARITAN HOME OF QUINCY 2130 Harrison Street Quincy, IL 62301 APPLICATION FOR EMPLOYMENT (Pre-Employment Questionnaire) (An Equal Opportunity Employer)
Present Address Street City State Zip
Permanent Address Street City State Zip
Phone No. Are You 16 Years or Older Yes No
Are you either a U.S. Citizen or An Alien Authorized to Work in the United States? Yes No
Are You Employed Now Yes No If So, May We Inquire of your Present Employer Yes No
Ever Applied To This Company Before? Yes No When? Were You Hired? Yes No
Referred By
Have you ever been convicted of a crime? Yes No
If Yes, Please Explain. (Do not disclose any conviction or arrest for which the records have been sealed or expunged)
GENERAL
Subjects of Special Study/Research Work/Special Skills
Activities (Civic, Athletic, Etc.) Exclude Organizations, The Name of Which Indicates the Race, Creed, Sex, Age, Marital Status, Color or Nation of Origin of Its members.
U.S. Military or Naval Service (if applicable) Rank Present Membership in Yes No National Guard of Reserves
FORMER EMPLOYERS (LIST BELOW LAST THREE EMPLOYERS, STARTING WITH CURRENT EMPLOYER FIRST)
WORK REFERENCES (Give the names of three persons not related to you, whom you have known at least one year)
PERSONAL REFERENCES (Give the names of three persons not related to you, whom you have known at least one year)
IN CASE OF EMERGENCY NOTIFY Name Address Phone No.
I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU.
I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE AND WITHOUT CAUSE.
Date Full Name (Please type in your full name)
This form has been designed to strictly comply with State and Federal fair employment practice laws prohibiting employment discrimination. The Age Discrimination in Employment Act of 1987 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. Updated 022201 application for employment 1
Please complete the following Work Availability Section
WORK AVAILABILITY RECORD
Primary position desired
Will you accept another position? Yes No If so, what position?
Weekends? Yes No Are you available to work Holidays? Yes No Rotating Shifts? Yes No
PLEASE INDICATE DAYS AND HOURS (including a.m. and/or p.m.) YOU ARE AVAILABLE FOR WORK (Be specific)
Do you have responsibilities that would limit your availability? Yes No
If yes, explain
IF YOUR AVAILABILITY CHANGES, IT IS YOUR RESPONSIBILITY TO NOTIFY YOUR SUPERVISOR INDICATING THE CHANGES. SUCH CHANGES WILL BE EFFECTIVE, THEN, FOR ANY FUTURE EMPLOYMENT.
I UNDERSTAND THAT EMERGENCY CONDITIONS MAY REQUIRE ME TO TEMPORARILY WORK SHIFTS OTHER THAN THE ONE FOR WHICH I AM APPLYING AND AGREE TO SUCH SCHEDULING CHANGE AS DIRECTED BY MY DEPARTMENT HEAD OR ADMINISTRATOR OF THIS HOME.
Applicant's Signature (Please type full name) Date
Please press the "submit" button to complete the online application process.
Once submitted, please scroll to the top of the page and read the message that appears. If the message describes an error, please call us at (217) 223-8717 to report the error.
If you would like more information about the Good Samaritan Home, please contact Missy Loos, Human Resources Director at (217) 223-8717 or by email at mpeters@gshq.org