8211 Weller Road   Montgomery, Ohio 45242

 

Your idea of a Nursing Home is about to Change...

...
Home Up

Please provide the following  information:

Name:
  
 Address:
    
City:    State:     Zip:

Home Phone:    Work  Phone:    Mobile Phone:

E-mail
 Social Security #

What Position are you applying for?    

Have you been employed by Meadowbrook Care Center before?


Dates of Employment: Department:

Are you related to anyone presently employed by Meadowbrook?
 No Yes - If Yes, who?:

Have you ever been convicted of a crime?
 No Yes - If Yes, please explain:
 

Have you ever been injured at work?
No Yes

Do you have a valid Ohio Drivers License?
No Yes

Do you have a valid C.D.L.?
No Yes

Are you a US citizen?
No Yes
     If No, Visa Class:

Are you available to work rotating shifts if the position you are applying for requires it?
No Yes

Are you a veteran of the United States Military Service?
No Yes - Branch: Dates:
     Please fax official documents certifying honorable veteran's status to 513-247-2943

Education
High School Graduate or Equivalent?
No Yes
Last Attended: High School College Other:
Course of Study?  
Dates Attended:
Name of School:
Location:
Degree (BS, BA, MA, etc):
   

List Special Skills or Qualifications:
Typing Skills:
No Yes - Net wpm:  

Computer Skills: (check all that apply)

Word   Excel   Publisher   Access

ACT!    Outlook
 
Professional or trade license, certificates or registrations: (RN, LPN, LSW, etc.)
Type:     
Number:  
State:  
Effective Dates of Employment:
Other Skills or Qualifications:
 
 

Employment History (Most recent position first)

Company Name:  
Address:  
Telephone Number:  
Job Title:  
Full Time Part Time Volunteer
Job Description:
  
 
Supervisor: 
Dates of Employment:
Starting Wage: $
Ending Wage: $
Reason for leaving:
 


 
 
Company Name:  
Address:  
Telephone Number:  
Job Title:  
Full Time Part Time Volunteer
Job Description:
  
 
Supervisor:  
Dates of Employment:
Starting Wage: $
Ending Wage: $
Reason for leaving:
  


 
   
Company Name:  
Address:  
Telephone Number:  
Job Title:  
Full Time Part Time Volunteer
Position:
  
 
Supervisor:    
Dates of Employment:
Starting Wage: $  
Ending Wage: $  
Reason for leaving:
  


 
 


References:

Give name, address and telephone number of three references who are not related to you and are not previous employers.

Name:  
Address:  
Phone Number:  
Occupation:  
Years Known:  
   

 
Name:  
Address:  
Phone Number:  
Occupation:  
Years Known:  
   

 
Name:  
Address:  
Phone Number:  
Occupation:  
Years Known:  
   
 
Why have you chosen to apply for a position with us?

What do you like about working with the elderly?

How  did you hear about Meadowbrook?
Employment
 Preference
 

Trinity Healthcare Corporation is an Equal Employment Opportunity Employer

TRINITY HEALTHCARE  IS AN EQUAL OPPORTUNITY EMPLOYER. No person employed by Trinity or seeking employment with the organization shall be appointed, promoted, reduced, removed, or in any way favored or discriminated against because of political or religious opinion or affiliations, race, color, sex, national origin, or physical handicap. The submittal of this document via e-mail constitutes your acknowledgment that the information provided is true to the best of your knowledge. Any misrepresentations will be reason for dismissal.

I agree that any false statements in this application will be sufficient cause for rejection or dismissal. I hereby grant permission to investigate any of the statements in this application and to submit to a medical examination if required. The use of this application does not indicate positions are open and does not obligate Trinity Healthcare.

For More Information or a Tour...  513-489-2444

 

 

 

 

Meadowbrook is a proud supporter of the Trinity Foundation International

Mondays at 5 pm - Channel 4; 

Wednesdays at 6:30 pm - Channel 24;

Thursdays at 9:00 am - Channel 4;  on Time Warner Cable

MCC - Proud Sponsor of Quality Educational Television
Send mail to  mitchbowman@trinitycorporation.com with questions or comments about this web site.
Copyright © 2009 The Trinity Companies
Last modified: January 04, 2009