Application Form

Name*

First Name

Middle Name

Last Name

Social Security #

Telephone # *

Address *

City

State

Zip Code

Age - only if under 18 years of age.

How were you referred to us? *

US Citizen or permitted to work in US? * Yes No

Alien Registration #

Person to contact if we cannot reach you *

Relationship to contact *

Contact Phone *

Position Applying For *

Date You Can Start *

Salary Requirements

FullTime
PartTime
PRN

Shift Preferred: * 1st
2nd
3rd
Weekends Only

Weekends Acceptable? * Yes No

Have you ever been employed by a Fox Subacute facility? * Yes No

If previously employed by Fox Subacute, When were you previously employed?

If previously employed by Fox Subacute, At which facility were you previously employed?

If previously employed by Fox Subacute, What position were you previously employed in?

Were you employed under a different name? Yes No

If you were previously employed under a different name, state the name used:

Have you been a resident of Pennsylvania for (2) years (without interruption) immediately preceding this date of application? * Yes No

Name of High School Attended

City

State

Last Grade Completed (High School)

Field of Study (High School)

Graduated (High School)

Name of College/University School Attended

Address (College/University)

City

State

Zip

Years Completed (College/University)

Field of Study (College/University)

Graduated (College/University)

Name of Technical/Business School Attended

Address (Technical School)

City

State

Zip

Years Completed (Technical)

Field of Study (Technical)

Graduated (Technical)

Name of Other School Attended (Special Training)

Address (Other School)

City

State

Zip

Years Completed (Other School)

Field of Study (Other School)

Graduated (Other School)

Typing Skills * Yes No

Typing Speed (WPM)

Other Skills / Comment

Computer Skills * Yes No

Computer Applications You Know:

FOX SUBACUTE CENTERS RESERVE THE RIGHT TO DRUG TEST

THIS SECTION TO BE COMPLETED BY LICENSED APPLICANTS
(RN, LPN, CNA, RESPIRATORY, SOCIAL WORK, PT, OT, SPEECH, RECREATION, THERAPY, DIETICIAN)

Where did you receive your professional training?

From (date)

To (date)

Place of Registration

Registry - Certification License #

FOLLOWING TO BE COMPLETED BY ALL APPLICANTS
PLEASE BEGIN WITH YOUR MOST RECENT EMPLOYER

Present or Last Employer *

Address (Present/Last Employer) *

City

State

Zip Code

From (Date) *

To (Date) *

Supervisor *

Phone *

Position *

Salary *

Reason for Leaving *

May We Contact Your Employer? * Yes No

Previous Employer

Address

City

State

Zip Code

From (Date)

To (Date)

Supervisor

Phone

Position

Salary

Reason for Leaving

May We Contact Your Employer? Yes No

Previous Employer

Address

City

State

Zip Code

From (Date)

To (Date)

Supervisor

Phone

Position

Salary

Reason for Leaving

May We Contact Your Employer? Yes No

Upload Your Resume

PLEASE READ BEFORE SUBMITTING:

I CERTIFY THAT THE INFORMATION ON THIS APPLICATION IS CORRECT AND MAY BE INVESTIGATED. I understand that if in the judgment of Fox Subacute Centers information that has been misrepresented, falsified, or omitted any offer of employment may be withdrawn or any employment terminated without obligation or liability on the part of the Company. I authorize Fox Subacute Centers to act as my AGENT in obtaining information from any person or company concerning myself, without liability to such person or company, or to Fox Subacute Centers.

I understand that Fox Subacute Centers operate 24 hours per day, 7 days per week and that weekend work or changes may be required during my employment. I understand that the examining physician may disclose the findings to any authorized agent of Fox Subacute Centers.