Job Application FormTo be considered for this position, please fill out all required fields truthfully and accurately. Personal InformationName* First Last Email* Phone (Cell)*Phone (Home)Home Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 1. Have you ever worked under another name?*YesNoGive Name*2. How did you hear about us?* Newspaper Peconic Landing Associate Employment web site/Indeed Our web site Social media Job Fair Other Please Specify*3. Have you ever filed an application with us before?*YesNoApplication Date4. Have you ever been employed with us before?*YesNoPrevious Employment Dates*5. If you are under 18 years of age, can you provide required proof of your eligibility to work?*YesNo6. Are you legally eligible for employment in this country?*YesNoIf yes, proof of citizenship/immigration status will be required upon employment.7. Have you been convicted of a crime (misdemeanor/felony)*YesNoPlease Explain*Employment DesiredPositionPlease ChooseCare Partner/RSACertified Nursing Aide (CNA)Clinical Manager Home Health ServicesCompanionsCookCustodianDietary Aide/ServerHome Health AidesHousekeeperLicensed Practical NursePersonal Care AidesPhysical TherapistPrep-CookReceptionistRegistered NurseSecurity/MaintenanceUtility/DishwasherDate you can start* Date Format: MM slash DD slash YYYY Work Availability* Full Time Part Time Temporary List days and hours available below*Sunday: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Education and SkillsEducation History Type of School School Name   Edit Delete There are no Entries. Add Entry Licenses / CertificationsPlease list any licenses or certifications applicable for this position.License / Certification TypeIssue Date Work ExperienceList 5 or more years starting with your current or most recent job.Work Experience Dates Employed Place of Employment Job Title   Edit Delete There are no Experiences. Add Experience ReferencesList three (3) professional contacts with whom you have worked.ReferencesNameRelationshipPhoneYears Known Cover Letter & ResuméPlease upload your Cover LetterAccepted file types: docx, doc, pdf.Please upload your ResuméAccepted file types: docx, doc, pdf.Agreement & CertificationRead carefully before signing.I have read and fully understand the questions asked in this application. I affirm that all answers given by me are true, accurate and complete. I understand and agree that any misrepresentation by me in this application or any other materials submitted by me to Peconic Landing will be sufficient cause for cancellation of this application and/or separation from employment with Peconic Landing if I have been employed. I give Peconic Landing permission to use any information in this application, to enable it, and its agents to verify the information contained in this application. I hereby release from liability Peconic Landing and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. This application is current and considered active for a period of six months from the date signed below. At the conclusion of this time, if I have not heard from Peconic Landing and still wish to be considered for employment, it will be necessary for me to fill out a new application. I understand that if hired, I will be an “at will” employee and for no definite period of time, and that I may leave Peconic Landing or Peconic Landing may ask me to leave its employ at any time with or without cause. I agree to comply with Peconic Landing policies and recognize that failure to comply may result in my dismissal. I understand that no manager or representative of Peconic Landing, other than the CEO or his designee, 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, and then, only if the agreement is expressly set forth in a written document signed by the associate. I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge, including information provided about my citizenship or alien status. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. Consumer Notice: Please be advised that a consumer report may be obtained from a consumer reporting agency for the purpose of evaluating you for employment, promotion, reassignment or retention as an employee.Signature*Candidate Name* Candidate Phone*Candidate Email* Candidate DecisionNameThis field is for validation purposes and should be left unchanged.