GoldPine Home » Job Application: LPN – Licensed Practical Nurse

Fields marked with an asterisk (*) must be filled out before submitting.

Applicant Information

First Name *
Middle Name
Last Name *

Contact Details

Email Address *
Street Address *
City *
State *
Zip Code *
Phone *
If hired, do you have a reliable means of transportation to work? Please describe.
List any special skills or training:
Salary Desired:

Employment Information

Are you seeking full time, part time or temporary employment?	Full time Part time Temporary
Which shift(s) would you prefer to work?	AM (6am – 2pm) PM (2pm – 10pm) Night (10pm – 6am)
Are you a student? If yes, please describe school schedule:
Please list times you are not available to work:
Are you willing to work overtime, weekends or holidays?	Overtime Weekends Holidays
Are you currently employed?
If hired, when would you be able to start?
Have you ever worked for this organization before? If yes, were you employed under the same name?
List any friends or relatives employed by this company:
Have you ever been discharged or asked to resign from any position? *	Yes No
Resume Upload (optional)

Education

Elementary (indicate highest achieved)
Name of School:
Location of School:
Secondary (indicate highest achieved)
Name of School:
Location of School:
College (indicate highest achieved)
Name of School:
Location of School:
Degree & Major:
Minor:

Work History (most recent first)

Company #1:
Phone No. with Area Code:
Address:
Dates of Employment:
Salary (beginning and end):
Job Title:
Supervisor’s Name & Title:
Describe duties briefly:
Specific reason for leaving:
Company #2:
Phone No. with Area Code:
Address:
Dates of Employment:
Salary (beginning and end):
Job Title:
Supervisor’s Name & Title:
Describe duties briefly:
Specific reason for leaving:
Company #3
Phone No. with Area Code:
Address:
Dates of Employment:
Salary (beginning and end):
Job Title:
Supervisor’s Name & Title:
Describe duties briefly:
Specific reason for leaving:
Have you worked for any of these organizations or attended school under a different name? If yes, give name and organization(s):
May we contact the employers listed above? If not, list the employers you do not wish us to contact and why:
Additional comments:

Authorizations

I certify that I have personally completed this application. I declare that the information provided in this employment applica-tion is true and complete and I understand that any false information or significant omissions may disqualify me from further con-sideration for employment and may be justification for my dismissal from employment if discovered at a later date. I agree to im-mediately notify this company if I should be convicted of a crime while my job application is pending or during my employment, if hired.

I authorize this company to make an investigation of all information contained in this employment application and I release from liability all companies and corporations supplying such information. I understand any false answers, statements, or implica-tions made by me on this application or other required documents shall be considered sufficient cause for denial of employment or discharge.

I specifically authorize and direct my current and former employers to supply employment-related information to this company and do hereby release my current and former employers from liability for providing information to this company.

Upon termination of my employment for whatever reason, I release this company from all liability for supplying any infor-mation concerning my employment to any potential employer.

I authorize this company, if applicable, to request a copy of my credit report, motor vehicle driving record, and any other inves-tigative report deemed necessary through various third party sources. As required by law, upon request within a reasonable period of time, I will be notified as to the nature and scope of such investigations.

I hereby agree to submit to any drug test required of me, whether prior to my employment or if employed by this company at any time thereafter. Employment is contingent on a negative drug test. If requested, I will take a post-job offer physical examination and my employment, in the event I receive medical treatment for any condition, including a physical, psychological, emotional, or psychiatric condition that is job-related, I hereby authorize the limited release and exchange of such medical information relating to my condition between the treatment provider and a company-designated physician.

At-Will Employment Agreement

I understand and agree that nothing contained in this application, or conveyed during any interview is intended to create an em-ployment contract between the company and me. In addition, I understand and agree that if you employ me, in consideration of my employment, my employment and compensation will be at-will, for no definite period of time, and may be terminated at any time, for any reason, or for no reason at all. I understand that only the company’s President is authorized to change the employment-at-will status and such a change can only be done in writing. I have read, understand, and agree to the above.
	* I have read and understood the Authorizations & At-Will Employment Agreement.