Pre-Employment Questionnaire

You can now apply for employment at St. Anne Home online!  Just fill out all of the items on the form below and click Submit.  Your application will be sent directly to St. Anne Home's Director of Human Resources.

Personal Information
Your full name:
Your address:
Telephone:
Type of position you are applying for:
Are you willing to work
Are you willing to work weekends:
On what date will you be available for work?
If employed and under 18 can you furnish a work permit?
Are you on a lay-off and subject to recall?
Are you legally eligible for employment in this country?
Are you a veteran of the U.S. Military Service?
If Yes, please indicate type of discharge:
Have you ever been terminated by a previous employer?
If Yes, please explain:
Have you been convicted of a felony?
If Yes, please explain:
Have you ever been convicted of Medicare fraud?
Have you ever been excluded from participation in federal health care programs?
Have you ever been employed by St. Anne Home before?
If Yes, give dates of employment: From: To:
Department:
Have you ever worked in a home for the aged or other healthcare facility?
Why are you interested in working for St. Anne Home?
Employment History
Start with your present or last job.  Indicate military service assignments and volunteer activities.  Please explain any gaps in employment in the comments section below.
Employment History #1
Employer:
Telephone:
Dates Employed From: To:
Nature of work:
Address:
Weekly Salary:
Immediate Supervisor:
Reason for leaving:
Employment History #2
Employer:
Telephone:
Dates Employed From: To:
Nature of work:
Address:
Weekly Salary:
Immediate Supervisor:
Reason for leaving:
Employment History #3
Employer:
Telephone:
Dates Employed From: To:
Nature of work:
Address:
Weekly Salary:
Immediate Supervisor:
Reason for leaving:
Employment History #4
Employer:
Telephone:
Dates Employed From: To:
Nature of work:
Address:
Weekly Salary:
Immediate Supervisor:
Reason for leaving:
Educational Background
High School:
Years completed:
Date of graduation:
College:
Years completed:
Date of graduation:
Graduate/Professional:
Years completed:
Date of graduation:
Please summarize your special skills and qualifications acquired from training, apprenticeships, and previous employment:

St. Anne Home is an Equal Opportunity Employer