Walton Nursing

& Adult Day Health Services, Incorporated

Committed To Promoting Healthy Lives

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	Job Application Module
	We offer challenging opportunities for people looking to join an organization that recognizes and rewards the contributions of its employees. Dynamic work environments, a wide range of career options, career advancement opportunities, plus the chance to join a leader in health care services. Just apply using the on-line job application below. Also try Georgia Dept Of Labor.

Applicant Personal Information
Application Date	11/21/2008
Position You Are Applying For Required
Social Security # Required
First Name Required
Middle Name
Last Name Required
Birth Date Required
Address Street Required
City Required
State Required
Zip Required
County Required
Home Phone # Required

Work Phone #

Pager

Cell Phone #
Are you at least 18 years of age? Required	Yes No

Are you legally eligible for employment in United States of America? Required	Yes No
Sex Required	Male Female
Ethnicity
Languages Spoken Besides English

Eligibility And Availabilty Information( if yes chosen, you must provide explanation and/or dates )
Have you ever been convicted of a crime? If yes, give date.	Yes No
Convicted From Date
Convicted To Date
Where were you convicted and what was the reason?

Have you been shown by credible evidence to have subjected a child or adult to serious injury and as a result of intentional or grossly negligent misconduct as evidence by an oral written statement to this effect obtained at the time of application? (Conviction is not an automatic bar to employment. Each case is considered individually.)	Yes No
If yes, please explain.
Are you related to any Walton Nursing & A.D.H. Services, Inc. employee? If Yes, state employee`s name and your relationship to them.	Yes No

Have you ever been employed with us before? If Yes, give date.	Yes No
If Yes, what was job title of previous position?

May we contact your present employer?	Yes No
If no, please state the reason.
Do you have a current CPR Certificate?	Yes No
CPR Certificate issued on
CPR Certificate issued by
Do you have a current First Aid Certificate?	Yes No
First Aid Certificate issued on
First Aid Certificate issued by

What is your desired salary range?

Are you available to work Weekends?	Yes No
Are you available to work Holidays?	Yes No
Are you available to work Rotating Shifts?	Yes No
Are you available to work On Call?	Yes No

Will you accept an alternate Job Position ?	Yes No
If yes, choose Alternate Position

Do you limit your annual earnings due to Social Security or other reasons?	Yes No
If yes, please state the maximum amount you wish to earn.

	I understand that emergency 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 institution.
Applicant, please sign your signature here.

High School Information

Did You Graduate?	Yes No
GED, CA Proficiency, or Diploma?	GED CA Proficiency Diploma
School Name
Location

Select Last Year Completed
Undergraduate Information

School Name
Credits/Units Completed
Did You Graduate?	Yes No
List Degree or Diploma
Course Of Study

Undergraduate Information

School Name
Credits/Units Completed
Did You Graduate?	Yes No
List Degree or Diploma
Course Of Study

Licenses And Certifications

Description(State if professional, trade, etc.)
Certificate/License #
Issued By
Expiration Date
	On the next page, beginning with your most recent experience and account for all time during the last ten years.


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