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St. Vincent's Home Inc.

Application For Employment

This application accepts secure information. Our website is secured with an SSL certificate to help protect this information. If you do not see a lock to the right of your address bar, then do not continue with this application. Please ensure that your computer is secure before continuing with this application. If you feel uncomfortable giving out this information online, please stop by our location to fill out the application.

St. Vincent's Home prohibits discrimination with respect to the hiring or promotion of individuals, conditions of employment, disciplinary and discharge practices or any other aspect of employment on the basis of sex, race, color, age, national origin, religion, disability, marital status, sexual orientation, gender identity, pregnancy or veteran status.

PERSONAL

Last Name: First Name: Middle:

Street Address: City, State, Zip:

Please enter your e-mail address (if you don't have e-mail, disregard this)
E-mail:

Home Telephone: Cell Phone:

Were you ever previously employed by St. Vincent's Home or Casita Catherine Assisted Living? If yes: Start Month Start Year End Month End Year

Location Social Security Number:--

Position Desired

Position Desired: Pay Desired: $

Type of employment desired: What hours are you available? What shift do you prefer?

Are you legally eligible for employment in the United States? When will you be available to begin work?

Special training and skills:

Education

Elementary School

          Name And Location:               Course Of Study:                No. Of Yrs Completed:

          Did You Graduate?                Degree Or Diploma:   

High School

          Name And Location:               Course Of Study:                No. Of Yrs Completed:

          Did You Graduate?                Degree Or Diploma:   

Business/Trade/Technical School

          Name And Location:               Course Of Study:                No. Of Yrs Completed:

          Did You Graduate?                Degree Or Diploma:   

College

          Name And Location:               Course Of Study:                No. Of Yrs Completed:

          Did You Graduate?                Degree Or Diploma:   

Graduate

          Name And Location:               Course Of Study:                No. Of Yrs Completed:

          Did You Graduate?                Degree Or Diploma:   

Employment

*Please give accurate complete full-time and part-time employment record. Start with present or most recent employer.

Company 1

Company Name:                    Telephone:

Street Address, City & State: Employed From: Month Year Employed To: Month Year

Name of Supervisor:             

State job title and describe your work:

Reason for leaving:

May we contact this employer:

Reason:


Company 2

Company Name:                    Telephone:

Street Address, City & State: Employed From: Month Year Employed To: Month Year

Name of Supervisor:             

State job title and describe your work:

Reason for leaving:

May we contact this employer:

Reason:



Company 3

Company Name:                    Telephone:

Street Address, City & State: Employed From: Month Year Employed To: Month Year

Name of Supervisor:             

State job title and describe your work:

Reason for leaving:

May we contact this employer:

Reason:



Company 4

Company Name:                    Telephone:

Street Address, City & State: Employed From: Month Year Employed To: Month Year

Name of Supervisor:             

State job title and describe your work:

Reason for leaving:

May we contact this employer:

Reason:

References

Please list 3 references - including address and phone number. (DO NOT INCLUDE RELATIVES)

Reference 1
Name: Address: Phone:

Reference 2
Name: Address: Phone:

Reference 3
Name: Address: Phone:

I hereby authorize St. Vincent's Home to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or St. Vincent's Home can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. I understand that it is the policy of St. Vincent's Home not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the ADAAA. I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

I fully understand and accept all terms and conditions in the above statement.

By typing my name in the following box I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my employment application and information. I acknowledge that my typed signature will be as binding as my actual signature.

Name:

If you were referred by a current employee, please type his/her name here:
Name:

Where did you hear about this job?     If other please tell us where: 

Click on file and then print or right click and click print to print a copy of this application for your records. If you have any trouble submitting the online application, please fax your printed copy to 217-277-2864.


The submission could take up to 60 seconds. Do not close your browser after you hit submit. Wait for at least 60 seconds before closing your browser. You will get a message popup that says APPLICATION SUBMITTED once the application has submitted successfully. If you do not get a successful application then fax your printed copy to (217) 277-2864 or bring a copy to 1440 North 10th Street Quincy IL 62301