Employment Application "*" indicates required fields Step 1 of 11 - Begin 9% Preferred Position*Please SelectFull Time Certified Nursing Assistant (CNA)Home Health AideHuman Resources ManagerActivities Aide and CNARegistered DietitianAvailability Full-Time Part-Time No Preference Salary Requirement (Annual)* Date Available to Start Employment* MM slash DD slash YYYY Your Contact InfoName* First Middle Last Maiden (if applicable) Your Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone (Primary)*Phone (Alternate)Email* Enter Email Confirm Email General InfoAre you authorized to work in the United States?* Yes No Are you over the age of 18 years?*(If no, you may be required to provide authorization to work) Yes No Did you server in the U.S. Military?* Yes No Date of Discharge* MM slash DD slash YYYY Type of Discharge*Note: A dishonorable or general discharge is not an absolute bar to employment. Employment HistoryPlease list your previous employers in the fields below. List present/most recent employer first. A minimum of 3 is preferred. Select the "Add Another Employer" button to add more.Company/Agency Name* Company/Agency Phone*Company/Agency Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Supervisor* Supervisor Job Title* Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Salary/Rate* Salary/Rate Per* Hour Week Year Employment Status*Please SelectFull-TimePart-TimeContractList of Duties*Reason for Leaving*Company/Agency Name (02)* Company/Agency Phone (02)*Company/Agency Address (02)* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Supervisor (02)* Supervisor Job Title (02)* Start Date (02)* MM slash DD slash YYYY End Date (02)* MM slash DD slash YYYY Salary/Rate (02)* Salary/Rate Per (02)* Hour Week Year Employment Status (02)*Please SelectFull-TimePart-TimeContractList of Duties (02)*Reason for Leaving (02)*Company/Agency Name (03)* Company/Agency Phone (03)*Company/Agency Address (03)* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Supervisor (03)* Supervisor Job Title (03)* Start Date (03)* MM slash DD slash YYYY End Date (03)* MM slash DD slash YYYY Salary/Rate (03)* Salary/Rate Per (03)* Hour Week Year Employment Status (03)*Please SelectFull-TimePart-TimeContractList of Duties (03)*Reason for Leaving (03)* Misc InfoHave you ever been convicted of, pled guilty or no contest to, a misdemeanor (last 3 years) or felony (last 7 years), other than minor traffic violations?*NOTE: A conviction is not an automatic disqualification for employment. Yes No If yes, please explain:*Have you ever been convicted of a crime including sex-related or child abuse related offenses?*NOTE: A conviction is not an automatic disqualification for employment. Yes No If yes, to any describe in full, including date(s):*Auto Insurance Company* Have you had more than 3 moving violations or more than one chargeable accident within the past three years?* Yes No Professional InfoProfessional Status*Administrative AssistantAideIntake CoordinatorMarketing CoordinatorMaster of Social WorkOccupational TherapistOtherPhysical TherapistRecreational TherapistRegistered dietitianRegistered NurseSpeech TherapistTransportation CoordinatorDo you have a Professional License, Certification or Registration?* Yes No License, Certification or Registration InfoState of Professional License, Certification or Registration*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense, Certification or Registration #* First Year Issued* Expiration Date* MM slash DD slash YYYY Has your Professional License, Certification or Registration ever been revoked, suspended or denied?* Yes No If Yes, what State?*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingIs your Professional License, Certification or Registration currently under investigation?* Yes No If yes, please explain:* ProficienciesAre you proficient in:*Check ALL that apply. ACCESS Calculator Copy Machine EXCEL FaxVoice Mail POWER POINT Publisher SQL Database WORD EducationEducation History*Please select all that apply. Attended High School/GED Attended College/Technical Attended Graduate Studies Currently Attending School High School* Years Completed*Select1234Did you graduate?*SelectYesNoDegree/Certificate* College/Technical School* Years Completed*Select1234Did you graduate?*SelectYesNoDegree/Certificate* Graduate Studies School* Years Completed*Select1234Did you graduate?*SelectYesNoDegree/Certificate* Current School Name* Current Course of Study* Expected Graduation Date* MM slash DD slash YYYY ReferencesPlease give complete and current information below for at least three references. Two references must be a former and/or current employer.Are you currently employed?* Yes No If yes, may we contact your current employer?* Yes No Current Employer* Current Supervisor* Current Employer Phone*Previous Employer* Previous Employer Supervisor* Previous Employer Phone*Previous Employer (02)* Previous Employer (02) Supervisor* Previous Employer (02) Phone*Professional Reference* Reference Affiliation* Reference Phone* Resume & DisclosureUpload Resume*Max. file size: 2 GB.Employment Disclosure*Please scroll to the bottom of the Employment Disclosure window to unlock the required checkbox below.I certify that my answers herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that any false, misleading, or incomplete information given during my application or interview (s) may result in denial of employment or in the termination of employment. I authorize PACE OF THE TRIAD to check my references and to verify information contained on this application. Further, I authorize former employers, personal references and others to give my information concerning me requested by PACE OF THE TRIAD, whether or not it is in their records, and I hereby release them from any liability whatsoever. By completing this application for employment with PACE OF THE TRIAD, I acknowledge that if employed I will be covered by the Company’s Alternative Dispute Resolution Program, and agree to accept this Program as a condition of my possible employment. I also understand that a copy of this Program may be obtained by contacting PACE OF THE TRIAD at (336) 550-4040. I understand that if I receive an offer of employment, I may be required to take a drug screen and/or physical abilities test. I understand that the offer and my continued employment may be contingent upon completed references, successful completion of these and any other required post-offer screens, and that I am required to abide by all rules and regulations of the employer. This application for employment shall remain active for 6 months. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with PACE OF THE TRIAD is of an “at will” nature, which means that I may resign at any time and PACE OF THE TRIAD may discharge me at any time with or without cause. I further understand that this “at will” employment relationship may not be changed by any written document or by conduct unless an authorized executive of PACE OF THE TRIAD specifically acknowledges such change in writing. I understand that by applying for a position for which driving a company vehicle is a job requirement; the Motor Vehicle Record will be checked prior to an employment offer. I understand that my employment may be contingent upon the receipt of an acceptable criminal history check received with my authorization. I understand that I may not be eligible for employment if I have had a felony conviction within the previous seven years and/or misdemeanor conviction in the previous three years involving violence, theft, and/or sexual misconduct. I have read, understood and agree to the Employment Disclosure. Signature*If you are using a desktop/laptop, please use your mouse (hold left-click and move) to sign. If you are using a mobile or touch screen device, use your finger.How did you hear of this position?* Referred by PACE Staff Member News Paper Professional Journal Website Google Search Other Which Staff Member?* Which Newspaper, Professional Journal or Website?* NameThis field is for validation purposes and should be left unchanged. Δ