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Answer all questions. A resume is not an acceptable substitute. Application for employment Friendship Haven, Inc. (FH,Inc.)

If you require some form of accommodation in order to complete the application process or to take any pre-employment tests which may be given, you may voluntarily identify in the space below the type of accommodation necessary.

Applicants are considered for all positions and employees are treated during employment without regard to race, color, religion, sex, national origin, age, I or any other prohibited basis of discrimination, as provided under applicable state and federal law.

Applicant Information


I understand that if I am employed by FH, Inc., any misrepresentation, falsification or omission on this application is sufficient cause for my dismissal. My continued employment will depend on the successful performance of work assigned to me during my trial period and upon the continued successful performance of work and the further need of my continued employment by FH, Inc. FH, Inc., in considering my application for employment, may verify the information set forth on this application and obtain additional information relating to my background. Provided that state/federal law permits, I further agree to submit to alcohol and/or drug screening tests and polygraph examinations if requested of me at any time prior to or during my employment with FH, Inc.

I understand that health care workers are required by law/regulation/policy to pass certain physicals from time to time. I further understand that if I do not pass any of these required physicals that I will not be able to work for FH, Inc.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between FH, Inc. and myself for either employment or for the providing of any benefit. I understand that no oral conversations are promises or guarantees regarding employment and that no such "promise" or "guarantee" is binding upon FH, Inc. If an employment relationship is established, understand that it is not for a stated period of time, but shall be "at will" and may be terminated at will by me or FH, Inc. with or without cause.

General Work History

Have you ever been employed by FH, Inc.?*

Are You Willing To Work Weekends?*
Are You Willing To Work Holidays?*

Are you physically and mentally able to perform the essential functions of the job for which you are applying with or without reasonable accomodation?

Please choose one:*

Do you have a record of founded child or dependent adult abuse in this state or any other state?

Please choose one:*

Have you ever been convicted of a crime, in this state or any other state?

Please choose one:*

A conviction record will not necessarily be a bar to employment. Factors,such as age and timing of offense, seriousness and nature of the violation and rehabilitation will be taken into account.

Do you have a nursing license?*
Type of license:*

Are you a certified nursing assistant?*

If hired, can you furnish proof that you are eligible to work in the United States? (if unsure of the documents needed to prove eligibility to work in the U.S., we will be happy to explain the legal requirements).

Please choose one:*

Educational History

High School(s)

Graduated (Yes/No)*

Graduated (Yes/No)*

Graduated (Yes/No)*

Graduated (Yes/No)*

Graduated (Yes/No)*

Add Another High School


Degree (Yes/No)*

Degree (Yes/No)*

Degree (Yes/No)*

Degree (Yes/No)*

Degree (Yes/No)*

Add Another College School

Business, Technical, Night or Correspondence

Grade level completed 0 1 2 3 4 5 6 7

Employment History

Begin with the most recent. May we contact your present employer?*

Employer 1

Employer 2

Employer 3

Employer 4

Employer 5

Add Another Employer


Please list names, addresses and telphone numbers of the three persons other than relatives and employers with whom you are acquainted.

Reference 1

Reference 2

Reference 3

Reference 4

Reference 5

Add Another Reference



I certify that the information contained in this application is correct to the best of my knowledge, and understand that any misrepresentation, falsification or omission in this application in any detail is grounds for disqualification from further consideration or for dismissal from employment at the time the company discovers any misrepresentation, omission or falsification. I agree to conform to the rules and regulations of FH, Inc. I understand that if hired I will be hired on the basis of "at will employment", and that my employment and compensation can be terminated with or without cause and with or without notice, at any time, at the option of either the company or myself.

I understand that this application is good only for one hundred twenty (120) days from date of application. If I still desire a position with FH, Inc. after this application expires, it will be my duty to fill out a new application and file it with FH, Inc. Otherwise, FH, Inc. will not consider me for employment after this application expires. I authorize and hold harmless all persons, schools, companies, agencies, corporations, businesses, credit bureaus, law enforcement agencies, and doctors to supply FH, Inc. with any information concerning my background/history.

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