Caring for you today,
tomorrow and always


Job application

For: RN Supervisor

By completing this application you are applying for employment at Jefferson Manor Health Center located in Brookville, Pennsylvania.

YES         NO

Record of Education

School Name School Address Course of study Highest grade completed? Did you graduate? List diploma or degree

Record of Employment

Dates Employed Name & Address of employer Job Title Salary Reason for Leaving Supervisor's Name
YES         NO
YES         NO
YES         NO

"Under the Immigration Control and Reform Act of 1986, any new employee (whether U.S. Citizen or resident alien) must provide at the time of employment, proof of identity, such as a driver's license with photograph, and authorization to be employed, i.e. birth certificate, social security card, U.S. passport, certificate of U.S. Citizenship or naturalization, resident alien card. If an employee is not able to do so, the employee will be discharged immediately."

Personal References

Full Name Address Phone Occupation Years known

Applicant: read this information carefully before signing

I certify that the answers given in this application and in the employment interview(s) are true and complete to the best of my knowledge.

Jefferson Manor Health Center is hereby authorized to make any investigation of all statements in the application, my personal history, educational background, military record, motor vehicle records, criminal records and credit history through their choice. I further authorize my former schools and personal references to provide any information they have regarding me. I hereby release all employers, schools and references from any liability for providing information concerning me.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I will be required to take and successfully pass a post-offer of employment physical, a PPD screening for tuberculosis and a criminal history background check. I understand that a criminal history background check will be requested from the PSP and/or the FBI. I also understand that my employment is provisional and continued employment is based upon the information to be received from the criminal justice agency. If the clearance request indicates convictions for crimes that prohibit my employment under Act 169 of 1996 and Act 13 of 1997, I understand that my employment must be terminated in compliance with state law. To the best of my knowledge I have never been convicted of a crime that would prohibit my employment at Jefferson Manor Health Center.

In consideration of my employment, I agree to conform to the rules and regulations of this employer, my employment and compensation can be terminated with or without cause, and employment status is of an "at will" nature. I understand that no company representative other than the Administrator has authority to enter into an agreement for employment for any specified period of time or make an agreement contrary to the foregoing. Jefferson Manor Health Center is an Equal Opportunity Employer and our personnel policies, procedures, and practices prohibit discrimination on the basis of race, color, national origin, religion, gender, age, veteran status, political affiliation, sexual orientation, marital status or disability. Employment opportunities shall be provided for applicants with disabilities and reasonable accommodations shall be made to meet the physical or mental limitations of qualified applicants or employees.

There is no guarantee of a job offer or a job interview in completing this application blank. Any offer of employment may be withdrawn at the option of Jefferson Manor Health Center. The application must be completely filled out in order for it to be considered for employment. If the information provided on the application cannot be satisfactorily verified by employment reference checks, the application could be considered as incomplete. Due to the large number of applications we receive and the competitive nature of our employment process, specific reasons for employment decisions will not be released.

I also understand that this is NOT a secure website and I can send my resume and information via US mail to the address below if I do not wish to submit this information over an unsecured network. (Jefferson Manor, 417 Route 28, Brookville, PA 15825)

By typing my name here I understand all above information and wish to be contacted with regard to my employment interest.