Located in Athens, PA

A JDK Management Company Operated Facilty

200 South Main Street, Athens, PA 18810

Phone: 570-731-6919• Fax: 570-731-6917

We are An Equal Oppertunity Employer
Do you have any other experience, training, qualifications or skills which you feel make you especially suited for work at Athens Health and Rehab Center?
  Are you a U.S. Citizen? Yes No If No, Do You Possess an Alien Registration card? Yes No
U.S. Immigration form I9 Must be completed within 3 days of hiring.
Athens Health and Rehab Center is a 24/7 facility, when are you not available to work?

Sunday Monday Tuesday

Wednesday

Thursday Friday Saturday

Do you have any physical or mental condition which may limit your ability to perform the work for which you are applying?
Yes No Athens Health and Rehabilitation Center does not discriminate on the basis of race, color, religion, sex (including sexual harassment or pregnancy), national origin, ancestry, age (over 40), mental or physical disability, veteran status, medical condition, marital status. Sexual orientation or political activity.
If you would be hired, will you have reliable transportation to and from the work site?
Have You Ever Been Convicted Of A Felony Yes No
References
List below three references that have known you for at least one year.(Please exclude relatives)
Education
Type Of School Name & Address Course of Study Did You Graduate? List Degree Or Diploma
High School Yes No
College Yes No
Business Or Trade Yes No
Certification Yes No
Work History (List most recent employer first)
  Hire Date Termination Date Employer Name, Address, Supervisors Name/ Phone Job Title and Duties Starting Salary Per/Hr Ending Salary Per/Hr Reason For Leaving
#1.
#2.
#3.
#4.
#5.
May we contact the past / present employers listed Yes No
If no, Indicate those you do not want us to contact:

I authorize the investigation of all statements contained in this application, except where I have requested on this form that no investigation be made. I hereby certify that the facts set forth in this application are true and complete to the best of my knowledge. I understand that if employed, falsified statements on this application show be considered sufficent cause for dismissal. I HEREBY AGREE and understand that if hired, my employment is for an indefinite period of time; that regardless of how long I work for Athens Health and Rehabilitation Center, I may be disciplined, laid-off, and/or discharged at any time without cause and with or without notice; and that I at all times during my employment serve merely at the will and pleasure of Athens Health and Rehabilitation Center, notwithstanding any other expressed or impled written or oral policies, procedures, or statements by any individual which have been or may have made to the contrary.

Applicant Signature


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