Employment Application 1234 PERSONAL INFORMATIONFirst* Middle Last* Have you ever used another name? If yes, please tell us the name.AddressPhone*Email Which facility are you applying for? Vista Pacifica Center - Locked Psychiatric SNF/IMD Vista Pacifica Convalescent - Geropsych SNF Date of Birth: MM slash DD slash YYYY Driver’s License Number: Are you CPR certified? If yes, please enter the dates of expiration?Are you at least 18 years of age? Yes No Professional License Number License Type If you are not a U.S. citizen, do you have the legal right to remain permanently and work in the U.S.? Yes No How did you learn about our organization? Advertisement Internet Friend Relative Craigslist Indeed What languages other than English do you speak? Can you speak this language fluently? Yes No Social Security Number Please note that this is not a secured form. Please add at your discretion. EMPLOYMENT DESIREDPosition You Are Applying For Salary/Wage desired? Do you require any accomodations to perform the essential functions of the position for which you are applying? Yes No Shift(s) You Can Work Days Evenings Nights Any What date would you be available for work? Type of Work Full Time Part Time Have you ever been employed with us before? Yes No If you answered yes to the above, please supply us with the date. List friends or relatives working in the company.Explain any gaps in employmentPlease list those other than personal illness, injury or disability.Have you ever been fired or asked to resign from a job?Reply yes or no. If you reply yes, please explain.EDUCATIONHighest level of education you have completed? Name of last school attended? Degree attained? Vocational or trade training? REFERENCES List below three people not related to you.REFERENCE #1Name First and last.AddressPhoneEmail In what capacity do you know this person?REFERENCE #2Name First and last.AddressPhoneEmail In what capacity do you know this person?REFERENCE #3Name First and last.AddressPhoneEmail In what capacity do you know this person? WORK EXPERIENCE List below your work experience, starting with your present or last place of employment.EMPLOYMENT #1Dates of Employment Start DateEnd Date End DateName of Company AddressPhoneSupervisor's Name Position Held Reason for LeavingEMPLOYMENT #2Dates of Employment Start DateEnd Date End DateName of Company AddressPhoneSupervisor's Name Position Held Reason for LeavingEMPLOYMENT #3Dates of Employment Start DateEnd Date End DateName of Company AddressPhoneSupervisor's Name Position Held Reason for LeavingUpload your ResumeMax. file size: 64 MB.*** Please note, only PDF files will be accepted.Enter "Pacifica" into the box* CommentsThis field is for validation purposes and should be left unchanged.