Employment Application Form

Position Desired

‍Preferred shift(s): Day □  Evening □  Night □Which days/times are you not available to work? ________________________

• Registered Nurse (RN) □
• Licensed Practical Nurse (LPN) □
• Certified Nursing Assistant (CNA) □

VOLUNTARY SELF-IDENTIFICATION OF DISABILITY

• WHY ARE YOU BEING ASKED TO COMPLETE THIS FORM?
  
  Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.
  
  If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.
  
  HOW DO I KNOW IF I HAVE A DISABILITY?
  
  You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.
  
  DISABILITIES INCLUDE, BUT ARE NOT LIMITED TO:
  
  • Schizophrenia                                              
    
  • Muscular dystrophy                                      
    
  • Bipolar disorder                                                        
    
  • Multiple sclerosis (MS)                                                                
    
  • HIV/AIDS                                
    
  • Missing limbs or partially missing limbs          
    
  • Intellectual disability (previously called mental retardation)
    
  • Impairments requiring the use of a wheelchair
    
  • Cerebral Palsy
    
  • Post-traumatic stress disorder (PTSD)
    
  • Obsessive-compulsive disorder    
    
  • Autism
    
  • Major depression
    
  • Blindness
    
  • Deafness
    
  • Cancer
    
  • Diabetes
    
  • Epilepsy
    

Licensure/Certification Information

Educational Background

Previous/Current Employment Details

Professional References

Background Information