Nurse Aide Training Class Application

New CENA Application (Nurse Aid Training Class )

Step 1 of 6 - Basic Info

Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Are you 18 years of age or older?
- Yes
- No
Date Available for Employment*
MM slash DD slash YYYY
Status*
check all appropriate
- Full Time
- Part-Time
- Seasonal
- Temporary
Shift(s) Desired
check all appropriate
- Day Shift
- Evening Shift
- Night Shift
- Any Available
Have you been vaccinated for Covid-19?
- Yes
- No
Can You Work Holidays and Weekends
- Yes
- No
Are there any days or hours you cannot work?
- Yes
- No
Please Explain
What prompted you to apply to Eastwood?
- Employee Referral
- News Ad
Who?
Have you ever worked for Eastwood Nursing Center?
- Yes
- No
When?
Do you have any relatives or acquaintances who are employed by Eastwood?
Name Relation

Employer 1
Name of Employer
Name of Supervisor
Status
- Full Time
- Part Time
Hours worked per week?
Please enter a number from 0 to 168.
Phone
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position & Duties
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Reason for Leaving
Name of Employer
Name of Supervisor
Status
- Full Time
- Part Time
Hours worked per week?
Please enter a number from 0 to 168.
Phone
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position & Duties
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Reason for Leaving
Name of Employer
Name of Supervisor
Status
- Full Time
- Part Time
Hours worked per week?
Please enter a number from 0 to 168.
Phone
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position & Duties
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Reason for Leaving
Name of Employer
Name of Supervisor
Status
- Full Time
- Part Time
Hours worked per week?
Please enter a number from 0 to 168.
Phone
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position & Duties
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Reason for Leaving

Personal References
Provide two personal references that you have known for at least one year who are not related to you.
Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Professional References
Provide two references that are currently or have been your working supervisor.
Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Read the Following Statements Before Signing this Application
I voluntarily give this facility the right to make a thorough investigation of my past employment, including my past training session and inservice attendance, attendance, attendance record, and disciplinary actions. I agree to cooperate in such an investigation and release from all liability or responsibility this facility, and all persons, companies or corporations supplying such information. I consent to take physical examinations as may be required by this facility at such times and places as the facility shall designate. I understand that I will be required to follow the personnel policies and rules of the facility and that infractions of the rules may lead to dismissal. I understand that this facility follows the "Fair Employment Practice code", and there is no discrimination in the hiring of individuals unrelated to ability to perform the work required. I understand that if I am employed, it will be on a probationary or trial basis for a period of 640 hours. Upon my termination I authorize the release of reference information on my work. I understand that unforeseen conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as directed by my department head or administrator of this facility. I understand that this application will remain on file for six months from today's date and if I wish to be considered for training or employment consideration after that time, I need to update this application. If a job offer is made to me, I understand that it is contingent upon taking and passing a physical exam. I understand that my training or employment may be terminated for any misstatement or omission of fact appearing on this application form.
*
- I have read and agree to the above statements.

Name	Issued From	Number	Expiration Date

Name	Relation

New CENA Application (Nurse Aid Training Class )

Step 1 of 6 - Basic Info

Education

Employer 1

Personal References

Professional References

Read the Following Statements Before Signing this Application