New Jersey Eastern Star Home Job Application

Application for Employment

*Applications will remain on file for six months. Should you wish to be considered for employment after that time please re-apply.
Full Name*

First NameMiddle NameLast Name
Email Address*
Phone Number*

Area CodePhone Number
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Are you 18 years of age or older?*

YesNo
Are you a U.S. Citizen?*

YesNo
If you are not U.S. Citizen do you have a permit to work in the U.S.?*

YesNo
EMERGENCY CONTACT
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Alternate Phone Number*

Area CodePhone Number
Relationship*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Education
HIGH SCHOOL EDUCATION
Name of High School Attended:*
City/State of High School:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Major/Courses of Study:*
Diploma Received?*

YesNo
COLLEGE EDUCATION
Name of College Attended:
City/State of College:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Major/Courses of Study:
Highest Year Completed:

1st2nd3rd4th
Degree Received?

YesNo
Certifications/Licenses
Type of Certifications and/or Licenses (please list where you obtained it.)
Vocational, Trade, Other Training, Volunteer or Community Service related to position for which you are applying:

Employment History
JOBS
Name of Current or Most Recent Employer:*
Current or Most Recent Employer's Telephone #:*

Area CodePhone Number
Current or Most Recent Employer's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current or Most Recent Job Title:*
Date Position Started:

MonthDayYear
Date
Are you still in this position?*

YesNo
If you answered no, please choose the date this position ended:*

MonthDayYear
Date
Please describe the work you performed while in this role:*
Reason For Leaving:*

PREVIOUS JOBS
Name of Previous Employer:*
Previous Employer's Telephone #:*

Area CodePhone Number
Previous Employer's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Job Title:*
Date Position Started:*

MonthDayYear
Date
Date Position Ended:*

MonthDayYear
Date
Please describe the work you performed while in this role:*
Reason For Leaving:*
PREVIOUS JOBS CONT.
Name of Previous Employer:
Previous Employer's Telephone #:

Area CodePhone Number
Previous Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Job Title:
Date Position Started:

MonthDayYear
Date
Date Position Ended:

MonthDayYear
Date
Please describe the work you performed while in this role:
Reason For Leaving:

References

DO NOT INCLUDE RELATIVES/FRIENDS
REFERENCE 1
Name:*

First NameLast Name
Telephone:*

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Professional Contact Position*
REFERENCE 2
Name:*

First NameLast Name
Telephone:*

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Professional Contact Position*
REFERENCE 3
Name:*

First NameLast Name
Telephone:*

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Professional Contact Position*

EMPLOYMENT UNDERSTANDING:
New Jersey Eastern Star Home, Inc. is an equal opportunity employer. This facility does not discriminate in hiring or any other employment decision on the basis of race, color, national origin, handicap/disability unrelated to ability to perform the work required, sex, age, creed, ancestry, religious principles, marital status, nationality, affectional or sexual orientation, sex or atypical hereditary cellular or blood trait, or because of service in the Armed Forces of the U.S., in compliance with C.F.R. Parts 80, 84 and 91 and N.J.S.A. Title 10. No questions on this application are intended to secure information to be used for unlawful discrimination. I voluntarily give the institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying or receiving such information. I understand that any job offer I receive is contingent upon satisfactory completion of a physical examination. I consent to take the physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that if I am hired, nothing contained in this application or anything else I receive or am told, would create an employment contract or anything other than an employment at will situation. I also understand that false or misleading information given in this application or interview (s) may result in disciplinary action up to and including discharge. If employed, I will be required to complete an Employment Verification Form (I-9), and within three (3) days show satisfactory evidence of identity and eligibility for employment.
Applicant's Signature *

Clear
DateTime
Please upload a copy of your resume:

Browse Files

Cancelof
Is there anything else you want us to know that may affect our decision to hire you?*

Background Check Authorization
Name*

First NameMiddle NameLast Name
Former Name(s) and Dates Used:
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Social Security Number*
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Driver's License Number/State:*
Please Check:*

I hereby authorize New Jersey Eastern Star Rehabilitation and Nursing and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public health records.
Other Information:*

I hereby consent to New Jersey Eastern Star Rehabilitation and Nursing furnishing such information described above if necessary to fulfilling its official responsibilities regarding my application for certification. I hereby release individual, agency and institution from any and all liability for damages of whatever kind which may result from complying or attempting to comply with this authorization and request to release information. I may be contacted at the address indicated above should there be any questions as to the validity or authenticity of this release.
Other Information:*

I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to New Jersey Eastern Star Rehabilitation and Nursing or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have to include information or date received from other sources. New Jersey Eastern Star Rehabilitation and Nursing and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicant's personal information, including, but not limited to, addresses, social security numbers, and dates of birth.
Signature*

Clear
Date*

MonthDayYear
Date
Notice to California, Minnesota, and Oklahoma Residents:

Please check the box below if you wish to receive a copy of a consumer report that is requested.
Please Check:

I wish to receive a copy of any Background Check Report on me that is requested.
Should be Empty: