Employment Application 1 2 3 4 PERSONAL INFORMATIONFirst*MiddleLast*Have you ever used another name?If yes, please tell us the name.AddressPhone*Email Which facility are you applying for?Vista Pacifica CenterVista Pacifica ConvalescentDate of Birth: Date Format: 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?YesNoProfessional License NumberLicense TypeIf you are not a U.S. citizen, do you have the legal right to remain permanently and work in the U.S.?YesNoHow did you learn about our organization?AdvertisementInternetFriendRelativeCraigslistIndeedWhat languages other than English do you speak?Can you speak this language fluently?YesNoSocial Security NumberPlease note that this is not a secured form. Please add at your discretion. EMPLOYMENT DESIREDPosition You Are Applying ForSalary/Wage desired?Do you require any accomodations to perform the essential functions of the position for which you are applying?YesNoShift(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?YesNoIf 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 #1NameFirst and last.AddressPhoneEmail In what capacity do you know this person?REFERENCE #2NameFirst and last.AddressPhoneEmail In what capacity do you know this person?REFERENCE #3NameFirst 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 EmploymentStart DateEnd DateName of CompanyAddressPhoneSupervisor's NamePosition HeldReason for LeavingEMPLOYMENT #2Dates of EmploymentStart DateEnd DateName of CompanyAddressPhoneSupervisor's NamePosition HeldReason for LeavingEMPLOYMENT #3Dates of EmploymentStart DateEnd DateName of CompanyAddressPhoneSupervisor's NamePosition HeldReason for LeavingResumeAccepted file types: pdf, doc, docx.Please attach your resume here.CAPTCHA