Having trouble filling out the form? Please download the application form and send it into us.

Have you been employed under a different name?
If yes, list names:
Alternate Phone:

Position(s) applied for:
Are you seeking (check all that apply):
Are you available (check all that apply):
Date available to start work?
Are you at least 18 years old?
Have you been previously employed at Shorehaven?
If so, when?
Have you previously completed an employment application?
If so, when?
Referral source:

High School

High school name:
High school address:
Number of years completed:
Course of study:
Certification or degree:


College school name:
College school address:
Number of years completed:
Course of study:
Certification or degree:


College school name: (1)
College school address:(1)
Number of years completed: (1)
Course of study: (1)
Certification or degree: (1)


Other school name:
Other school address:
Number of years completed:
Course of study:
Certification or degree:

Licenses/Certifications held

Expiration Date:

Additional job-related skills or qualifications:

Employment History

Current or most recent employer

Employer name:
Employer address:
Employer phone number:
Immediate supervisor:
Employment start date:
Employment end date:
Job title:
Final wage:
Reason for leaving:
May we communicate with your present employer?

Previous employer

Previous employer name:
Previous employer address:
Previous employer phone number:
Previous employer immediate supervisor:
Previous employer employment start date:
Previous employer employment end date:
Previous employer job title:
Previous employer duties:
Previous final wage:
Previous employer reason for leaving:

Previous employer

Previous employer name:(1)
Previous employer address:(1)
Previous employer phone number:(1)
Previous employer immediate supervisor:(1)
Previous employer employment start date:(1)
Previous employer employment end date:(1)
Previous employer job title:(1)
Previous employer duties:(1)
Previous final wage:(1)
Previous employer reason for leaving:(1)

Previous employer

Previous employer name:(2)
Previous employer address:(2)
Previous employer phone number:(2)
Previous employer immediate supervisor:(2)
Previous employer employment start date:(2)
Previous employer employment end date:(2)
Previous employer job title:(2)
Previous employer duties:(2)
Previous final wage:(2)
Previous employer reason for leaving:(2)
If you have a resume please upload it here:

Note: Providing the following information will not result in automatic disqualification of employment.

Have you ever been convicted of a felony, misdemeanor or ordinance violation other than a traffic violation?
If yes, please explain:
Are there charges pending against you?
If yes, please explain:
Do you have the legal right to be employed in the United States?
As a condition of employment, are you willing to receive a seasonal flu shot?


Reference name:
Company name:
Reference address:
Reference phone number:
Years known:

Reference name: (1)
Company name:(1)
Reference address:(1)
Reference phone number:(1)
Years known:(1)

Reference name: (2)
Company name:(2)
Reference address:(2)
Reference phone number:(2)
Years known:(2)

NOTICE TO APPLICANTS - Please read each paragraph carefully before signing:

I certify that this application was completed by me and all information provided by me in support of my application for employment is true and correct to the best of my knowledge. I understand that misrepresentations, omissions, false or evasive information may be cause for rejection, or may be cause for subsequent dismissal if I am hired.

I understand that an offer of employment extended to me will be contingent based on satisfactory physical examination including TB skin test or chest x-ray, a drug screen, employment references, and criminal background check (a criminal record does not constitute an automatic bar to employment and will be considered only as it relates to the job).

I hereby authorize any former employer, person, firm, corporation or government agency to answer any and all questions regarding my application and to release or provide any information within their knowledge or records. I agree to hold any or all of them blameless and free of any liability for releasing any truthful information that is within their knowledge or records.

I understand my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either Shorehaven or myself. I understand that no representative of Shorehaven, other than the CEO, has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.

Signature of Applicant:
Include CNA Registration Number if applicable