Employment Application

Federal and state law prohibits discrimination because of sex, race, color, religious creed, age, national origin, marital status, mental or physical disability, including, but not limited to, blindness.

Are you over the minimum legal working age YesNo

Full TimePart Time

If applying for nursing position, please complete:


If you chose other, please specify:

If applying for a nurses aide/home health aide position, please complete:

Certified: YesNo

Are you registered: YesNo


Please supply us with a history of employment.

Employment History 1

Employment History 2

Employment History 3

May we contact the employers listed? YesNo

If you have worked under a different name at any of the job(s) listed above, please indicate the different name and when used:

Please supply us with three personal references (no relatives).

Reference Number 1

Reference Number 2

Reference Number 3

If hired, do you have a reliable means of transportation YesNo

Educational Background

Grammer/Grade School:

High School


Post Graduate

Business / Trade School

Legal Right to Work in the United States

Are you able, at the time of employment, to submit verification of your legal right to work in the United States? YesNo

Other Criteria for Evaluating Suitability for Employment

Disciplinary Action from Licensing Agency:

Suffield by the River requires that all prospective employees must completely answer these questions:

1. Have you ever been subject to disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory, or a foreign jurisdiction? If so, please identify the nature and the date of action, the licensing agency involved, and the underlying circumstances or other information to help us evaluate your current fitness for employment.

2. Have you ever been discharged from a job?

Limitations or Disabilities

1. Are you fully able to perform the duties of the job for which you have applied for without endangering yourself, other employees or residents?YesNo

I agree to take a physical examination at the Facility’s request at any time after I am offered a position. I also agree that the examining physician may disclose the findings of the examination to the Facility or its authorized agent. Further, I agree to release and hold harmless the Facility, its officers, agents and employees from any liability based upon the request for administration and use of the results of any physical examination.

Physicals are completed by a clinic preferred by Suffield by the River, at the employee’s cost. The name and address of the preferred clinic will be provided to employee.

Verification of Facts States by Application in this Application for Employment

I hereby certify that the facts set forth in the above Application for Employment are true and complete. I understand that falsification or elimination of facts will jeopardize hiring or constitute cause for dismissal. I also understand that employment will be on an employment-at-will status. I understand my employment can be terminated any time and for any reason by either the facility or by myself. If hired, I will abide by all rules and regulations, however, I understand that such rules may be changed at any time by the Facility as necessary.

Thank you for completing this application and for having an interest in employment with Suffield by the River. If there is not a current opening for the position for which you have applied, your application will be kept on file for 30 days in case of an opening. After that, the position must be re-applied for.

In compliance with the Civil Rights Act of 1964, Title VI, and other state and Federal Laws, this Facility will be fair and impartial in relations with personnel and applicants for employment – be it recruiting, discharging, transferring, training, layoff, compensation or terms, conditions or privileges of employment benefits – without regard to race, color, religious creed, age, sex, marital status, national origin, mental or physical disability, including, but not limited to, blindness.

Suffield by the River

Applicant's Authorization to Release Information

I hereby give permission to Suffield by the River to make inquiries to my current and former employers as noted by my selection of A or B below:

A At this time, my current and former employers may be contacted.

B At this time, just my former employers may be contacted. Once, however, a new job has been offered to me and/or I have left my current employment, Suffield by the River may, at that time, contact such employer.

I also give permission to Suffield by the River to make inquires to licensing or registration authorities (with respect to the current status, etc., of my professional license) and to any other party to verify other representations, including, but not limited to, my criminal history background, I have made in my employment application, resume, or during any interviews.

I agree not to hold anyone liable for such inquiries regarding my experience, character, and the reason for leaving any and all past employment.

I agree not to hold anyone liable for such inquiries regarding my experience, character, and the reason for leaving any and all past employment.

Original to be kept in employee file or with application before hire. Copy of this authorization will be sent with reference check.

Download Application for Employment

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