Employment Application

X/Twitter

This field is for validation purposes and should be left unchanged.

PERSONAL INFORMATION

First*

Middle

Last*

Have you ever used another name?

If yes, please tell us the name.

Address

Phone*

Email

Which facility are you applying for?

Vista Pacifica Center - Locked Psychiatric SNF/IMD

Vista Pacifica Convalescent - Geropsych SNF

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?

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 DESIRED

Position You Are Applying For

List Position Applying For

Salary/Wage desired?

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 employment

Please 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.

EDUCATION

Highest 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 #1

Name

First and last.

Address

Phone

Email

In what capacity do you know this person?

REFERENCE #2

Name

First and last.

Address

Phone

Email

In what capacity do you know this person?

REFERENCE #3

Name

First and last.

Address

Phone

Email

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 #1

Dates of Employment

Start Date

End Date

Name of Company

Address

Phone

Supervisor's Name

Position Held

Reason for Leaving

EMPLOYMENT #2

Dates of Employment

Start Date

End Date

Name of Company

Address

Phone

Supervisor's Name

Position Held

Reason for Leaving

EMPLOYMENT #3

Dates of Employment

Start Date

End Date

Name of Company

Address

Phone

Supervisor's Name

Position Held

Reason for Leaving

Upload your Resume

Accepted file types: pdf, Max. file size: 50 MB.

*** Please note, only PDF files will be accepted.

Please fill out completely.

PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION

REFERENCES

WORK EXPERIENCE

EMPLOYMENT #1

EMPLOYMENT #2

EMPLOYMENT #3

We value your privacy