Download application in PDF format.
Position Applied For:
Full Name:
Address:
City:
State/Zip:
Phone:
Social Security No.:
Are you a citizen of the United States?
Yes
No
Do you have work papers?
Yes
No
Have you been convicted of a felony?
Yes
No
Whitcomb House cannot employ anyone who has been convicted of a felony.
Are you a U.S. Veteran?
Yes
No
Branch of Service:
Check all that apply:
Are you willing to work:
Full Time
Part Time
On Call
Days:
Days Available:
Any Day
Mon.-Fri.
Weekends
Evenings:
Evenings Available:
Any Evening
Mon.-Fri.
Weekends
Nights:
Nights Available:
Any Night
Mon.-Fri.
Weekends
Education
(Name and location of school)
High School:
Did you graduate?
Program:
College or University:
Did you graduate?
Program:
Are you a Certified Nurses Aide?
Yes
No
(at least 54 hours of training)
Are you a certified Home Health Aide?
Yes
No
(at least 54 hours of training)
Training and Certification programs:
Do you have a valid Driver's License?
Do you have an automobile?
When are you available to start?
Previous Employment
(begin with most recent position)
Most Recent
Firm:
Address:
Position(s) held:
Dates of Employment:
Supervisor:
Ending Salary:
Reason for Leaving:
Previous Employer
Firm:
Address:
Position(s) held:
Dates of Employment:
Supervisor:
Ending Salary:
Reason for Leaving:
Previous Employer
Firm:
Address:
Position(s) held:
Dates of Employment:
Supervisor:
Ending Salary:
Reason for Leaving:
Please summarize your special skills or qualifications:
Why are you interested in Whitcomb House?
References
Please furnish the name and addresses of two people by whom you have been employed or supervised.
Name:
Phone:
Address:
Name:
Phone:
Address:
I certify that my answers are true and complete to the best of my knowledge.
I authorize you to make such personal investigations and inquiries of my personal, employment, credit, criminal, educational or medical history and other related matters as may be necessary for an employment decision. I hereby release employers, schools, or persons from all liability in responding to inquiries in connection with my application.
In the event that I am employed, I understand that false or misleading information given in my application or interview(s) may lead to my dismissal.
All potential applicants are evaluated without regard to race, color, religion, gender, national origin, age, marital or veteran status, the presence of a non-job related handicap or any other legally protected status.
245 West Street • Milford, Massachusetts 01757
Tel. 508-634-2440 • Fax 508-473-6366 •
Living@Whitcombhouse.com
Copyright © 2004 Whitcomb House
