Careers

Personal Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Email*

Work Permit*

If you are under the age of 18, do you have a work permit?

Yes

No

N/A

Employment Desired

Position applied for*

Shift you prefer*

Day

Evening

Nights

Hours desired*

Full-time

Part-time

How did you hear of this opening*

Date you can start*

Have you ever worked for this company before*

Yes

No

When*

Supervisor*

Reason for Leaving*

Employment

List below your work experience, starting with your most recent employment.

Employment*

Dates Employed

Name & Address of Employer

Supervisor

Phone

Reason for leaving

References

Please list three professional references. Do not include relatives.

References*

Name/Relationship

Company

Address

Phone

Email

Years Acquainted

Agreement*

I hereby certify that all entries and attachments are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any employment with Nehalem Valley Care Center. I understand that all information on this application is subject to verification and I consent to a criminal history background check. I also consent to references, former employers, and educational institutions listed being contacted regarding this application.

I agree

Name

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

Get in Touch

Careers

Open positions:

Application for Employment

Personal Information

Employment Desired

Education

Employment

References