PRE- EMPLOYMENT APPLICATION

PLEASE PRINT IN INK OR TYPE. APPLICATION MUST BE FULLY COMPLETED ( ON BOTH SIDES) FOR CONSIDERATION.
Date: _______________ Type of work desired (Application will be filed under 1 st choice):
1st choice: _________________________________________

2nd choice: ______________________________________________

Name: ___________________________________________________

Social Security Number: ____________________________

Address: ______________________________________ City: ______________ Zip:___________ Phone: (

) ______________

Person to contact in case of emergency: Name: ___________________________________________ Phone: (

) ______________

Work Preference: Full Time 

Part Time 

Relief

Per Diem

Shift Preference: Day 

Evenings 

Nights 

Have you ever worked or applied at Mt. San Antonio Gardens before?
Worked: Yes 

No 

If yes, when? ______________________

Applied: Yes 

No 

If yes, when? _______________

How were you referred to this organization for employment? __________________________________________________________

BACKGROUND DATA
1.

Do you have a legal right to work in the United States?............................................................ Yes 

2.

Are you 18 years of age or older? ............................................................................................. Yes 

3.

No 
No 

If under 18, can you (if offered employment) provide a work permit? ........................................................... Yes 

No 

Have you ever been convicted of a crime? .............................................................................. Yes 

No 

If “yes”, please explain: ________________________________________________________________________________
(PLEASE NOTE: A conviction will not necessarily disqualify you from employment. Each case will be considered on its own
merits.)
4.

Are you related to any of our employees? ............................................................................... .Yes 

No 

If “yes”, please give their name(s): _______________________________________________________________________

5.

On what date will you be available for work? ________________________________________________

EMPLOYMENT IS CONTINGENT ON THE ABILITY TO PASS A PHYSICAL EXAMINATION AND A DRUG AND
ALCOHOL SCREEN, PROVIDE ACCEPTABLE REFERENCES, AND SUBMIT PROOF OF IDENTITY AND LEGAL
ABILITY TO WORK IN THE UNITED STATES.
Mt. San Antonio Gardens is an equal opportunity employer. It is our policy to recruit, hire and promote for all job classifications on
the basis of merit, qualifications and competence. All employment decisions will be based on the individual’s qualifications related
to requirements of the positions being filled. Mt. San Antonio Gardens will hire only individuals who are legally able to work in
the United States.
PLEASE COMPLETE THE
REVERSE SIDE OF
THIS APPLICATION.

........___________ ___________________ _______________ ____________ _______________ College/University…………………………………………………………………………………………………………… ____________ _...................This section must be completed........... agencies and persons contacted to release any and all information in their possession which has or may have bearing on my suitability for employment... San Antonio Gardens is at the mutual consent of employer and employee............ San Antonio Gardens is a non-smoking facility.......... Include military service and unemployment...... Expiration Date: ……………….…………………………………………..... Signature: ______________________________________________________________ Date: ____________________________ _ ...... I understand a physical examination which includes a drug and alcohol screen by Mt.............…............. Provide all requested information for three references. Mt...... I understand that employment at Mt..... I authorize all former employers..... I agree to and understand the above statements.................. State: …………......... San Antonio Gardens physician will be required prior to my employment............. even if supplemented by a resume.........______________ Additional Education: ………………………………………………………………………………………………………… Professional Registry and/or License Number: ……………………... Dates of Employment Company Name and Address Phone Number Supervisor Title and /or Duties From:___________________________________________________________________________________________________ To: _____________________________________________________________________________________________________ Salary: _______________ Reason for Leaving: Dates of Employment ____________________________________________________________ Company Name and Address Phone Number Supervisor Title and /or Duties From:___________________________________________________________________________________________________ To: _____________________________________________________________________________________________________ Salary: _______________ Reason for Leaving: ____________________________________________________________ Dates of Employment Company Name and Address Phone Number Supervisor Title and /or Duties From:___________________________________________________________________________________________________ To: _____________________________________________________________________________________________________ Salary: _______________ Reason for Leaving: _____________________________________________________________ PERSONAL REFERENCES: (DO NOT list employers or relatives............. Foreign Languages: I read: …………………….... I speak: ………………………… I write: ……………………………… I understand any misrepresentation or material omission of information in this application or health service medical record will be cause for denial of employment or for dismissal if employed. and that the employment relationship can be terminated by either party................. companies.... I hereby certify that all the information included on this application is true to and complete to the best of my knowledge................................ Beginning with the present......................... list all jobs during the past ten years..) Name Address Phone Number ________________________________ ______________________________________________________________________ __________________________________________________________________________________________________________ _________________________________________________________________________________________________________ ____________________ ______________________________________________ _____________________ EDUCATIONAL RECORD: Name City/State # of Years Completed Major Diploma or Degree Last High School: _.......

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