Scotland House, Woodstock Area Adult Day Health and Wellness
ONLINE APPLICATION FORM - ALL fields with an " * " are required and must be completed in order to submit. If not applicable, please enter "na"
Email address *
PERSONAL INFORMATION
Name (First, MI, Last) *
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Mailing Address *
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Physical Address (if different)
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Home Phone *
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Alternate Phone
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Please indicate best way to contact
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POSITION DESIRED
Position applying for *
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Job Status *
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Shift *
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EDUCATION
High School, Location (complete address), Number of Years Completed *
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College, Location(complete address), Number of Years Completed, Major & Degree *
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Business/Trade/Technical, Location (complete address), Number of Years Completed, Major & Degree
Your answer
Graduate, Location (complete address), Number of Years Completed, Major & Degree
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PROFESSIONAL LICENSES/CERTIFICATIONS
Type/State/Number/Date Issued/Expiration date [Temp/Perm]
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Has your professional license/certification ever been conditioned, suspended, revoked, or otherwise restricted? If Yes, please explain. *
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EMPLOYMENT HISTORY
Please begin with your most recent employment and include all of your past employment. If more space is needed, please continue in the section that says "additional employment" history:
Job Title *
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Employer/Address/Telephone/Supervisor *
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Employed from - Employed to *
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Hrs/Week: *
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May we contact your current supervisor for a reference *
Job Duties *
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Starting Salary
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Ending Salary
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Reason for Transferring/Leaving? *
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Job Title
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Employer/Address/Telephone/Supervisor
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Employed from - Employed to
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Hrs/Week
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Job Duties
Your answer
Starting Salary
Your answer
Ending Salary
Your answer
Reason for Leaving?
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Job Title
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Employer/Address/Telephone/Supervisor
Your answer
Employed from - Employed to
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Hrs/Week
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Job Duties
Your answer
Starting Salary
Your answer
Ending Salary
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Reason for Leaving?
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Additional Job(s):
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PROFESSIONAL REFERENCES: Please list three references who are not relatives.
Name/Company/Phone Number/Relationship *
Your answer
Name/Company/Phone Number/Relationship *
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Name/Company/Phone Number/Relationship *
Your answer
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use this space to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.
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Please read:
I certify that all statements I have made on this application, my resume, and all documents related to my application are complete, accurate, and true to the best of my knowledge. I understand that my misrepresentation, false statement, or omission deemed material by Scotland House, Woodstock Area Adult Day Health and Wellness may result in Scotland House, Woodstock Area Adult Day Health and Wellness not hiring me or, if employed, terminating my employment. I understand that my acceptance of an offer of employment does not contractually bind Scotland House, Woodstock Area Adult Day Health and Wellness to continue to employ me in the future and that, unless I have a written employment contract, I will be an employee at will and Scotland House, Woodstock Area Adult Day Health and Wellness can terminate my employment at any time with or without cause.

I acknowledge and agree that references, prior employers, and other individuals or businesses providing Scotland House, Woodstock Area Adult Day Health and Wellness with information about me are doing so at my request. I hereby hold harmless and absolve Scotland House, Woodstock Area Adult Day Health and Wellness and any such individual(s) and/or businesses of any liability for claims or damages of any kind related to the obtaining, furnishing, or verifying such information. I also waive all rights to see or review information furnished to Scotland House, Woodstock Area Adult Day Health and Wellness.
I have read the above paragraph *
My electronic signature (typed here) is certification for the above paragraph. *
Your answer
Date *
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It is the policy of Scotland House, Woodstock Area Adult Day Health and Wellness to consider applicants for employment without regard to race, color, religion, age, disability, national origin, citizenship, place of birth, ancestry, gender, gender identity, sexual orientation, a positive test result from an HIV-related blood test, genetic information, veteran or military status, or any other status protected by state or federal law.
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