Blue Link - Online Employment Application System

Questionnaire

We like to provide candidates with an opportunity to provide additional information. It is important you answer the questions honestly, so that we can accurately assess your “fit” with the position you are applying for and our facility.

Position Apply For:

Desired Shift (if applicable)?

How did you hear about the Galeon Senior Liiving?

Newspaper Internet Job Fair Friend/Family

If you selected Internet, Which Website?

If you selected Friend or Family, please give us one name.

Some positions require a certification (C.N.A.) or license (LPN, RN, CDM, etc.), do you have a certification/license and if so in what field and are all requirements up to date?

Describe your experience that is most related to this position and where you obtain this experience?

Why are you interested in working for us?

What computer skills do you have?

What did you like most about your last (or current) position?

If an in-person interview is scheduled, you will be required to provide two original forms of ID (or a passport), one being a photo ID, a full background check will be performed before you can be hired.

I certify the information provided here is accurate.

Signed

Date:

Applicant

Last Name

First Name

Middle Initial

Date

Street Address

Apartment/Unit Number #

City

State

Zip Code

Phone

Email Address

Date Available

Social Security Number

Desired Salary

Position Applied For

Are you citizen of the United States?

Yes No

If no, are you authorized to work in the U.S.?

Yes No

Have you ever worked for this company?

Yes No

If so, when?

Education

High School

Address

Did you graduate High School?

Yes No

Diploma, Preferred Courses

College

Address

From

Did you graduate College?

Yes No

Degree, Preferred Courses

Other

Address

From

Did you graduate?

Yes No

Degree, Diploma, Preferred Courses

References

Full Name

Relationship

Company

Phone

Address

Full Name

Relationship

Company

Phone

Address

Full Name

Relationship

Company

Phone

Address

Previous Emp.

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for Leaving

May we contact your previous employer for a reference?

Yes No

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for Leaving

May we contact your previous employer for a reference?

Yes No

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for Leaving

May we contact your previous employer for a reference?

Yes No

Military Service

Branch

From

Rank at Discharge

Type of Discharge

If other than honorable, please explain:

Professional Info.

Type:

Organization or State Issued:

Date Issued

Number

Type:

Organization or State Issued:

Date Issued

Number

Type:

Organization or State Issued:

Date Issued

Number

Disclaimer & Sign.

I certify that all answers are true and complete to the best of my knowledge.

Signature (Please type your full name.)

Date

Galeon Senior Living - Online Employment Application System