HAVEN HEALTHCARE
ONLINE EMPLOYMENT APPLICATION

Haven Healthcare is an Equal Opportunity Employer. Federal and state laws prohibit discrimination in employment because of sex, age, race, color, religious creed, marital status, national origin, citizenship, ancestry, disability or handicap.

Required fields are denoted by *.

* Select The Facility Or Facilities You Are Applying To:

Connecticut
Haven Health Center of Cromwell
Haven Health Center of Danielson
Haven Health Center of East Hartford
Haven Health Center of Farmington
Haven Health Center of Jewett City
Haven Health Center of New Haven
Haven Health Center of Norwich
Haven Health Center of Rocky Hill
Haven Health Center of Soundview
Haven Health Center of South Windsor
Haven Health Center of Torrington
Haven Health Center of Waterbury
Haven Health Center of Waterford
Haven Health Center of West Hartford
Haven Health Center of Windham

Massachusetts
Haven Health Center of Chelsea

New Hampshire
Haven Health Center of Claremont
Haven Health Center of Derry
Haven Health Center of Seacoast (Hampton)
Partridge House (Hampton)

Rhode Island
Haven Health Center of Coventry
Haven Health Center of Greenville
Haven Health Center of Pawtucket
Haven Health Center of Warren

Vermont
Haven Health Center of Rutland
Haven Health Center of Saint Albans
Rutland Manor at Haven


* Position Applying For:

RN
LPN
CNA		 Physical Therapist
Occupational Therapist
Speech Therapist		 Housekeeping
Hospitality
Administrator
Other:

Personal Information:

* Full Name:        
* Street Address:
* City: * State:      * Zip Code:
* Home Phone: Alt. Phone:
* E-mail:        

Are you either a U.S. Citizen or an alien who has a legal right to reside and work in the U.S.A.?
Yes No

Have you been convicted of a felony within the last seven (7) years? Yes No

If you answered yes, please explain:

Employment Information:

Have you filed an application with us before? Yes No

If yes, give approximate date:

Have you ever been employed with us before? Yes No

If yes, what position and date:

Are you presently employed? Yes No

If yes, may we contact your present employer? Yes No

Date available for employment:

Type of employment: Full-Time Part-Time

Shift(s) available: 1st 2nd 3rd


Education:

Highest grade completed:

  Name of School City/State Diploma/Degree/Date
High School
College
CNA Program
Other Education

For Licensed Personnel Only:

I currently hold a license as a: RN LPN     Other license:

My license number is:      It expires:

Are you currently certified in CPR? Yes No

If yes, when is the renewal date?


Employment History:

List all work experience, starting with the most recent employment.

1.  Employer:        
  Street Address:
  City: State:      Zip Code:
  Supervisor:        
  Reason for Leaving:        
  Dates employed: From: To:
  Position:        
  Work Performed:
  Hourly Rate/Salary: Starting: Ending:

2.  Employer:        
  Street Address:
  City: State:      Zip Code:
  Supervisor:        
  Reason for Leaving:        
  Dates employed: From: To:
  Position:        
  Work Performed:
  Hourly Rate/Salary: Starting: Ending:

3.  Employer:        
  Street Address:
  City: State:      Zip Code:
  Supervisor:        
  Reason for Leaving:        
  Dates employed: From: To:
  Position:        
  Work Performed:
  Hourly Rate/Salary: Starting: Ending:

Personal References:

Please list two persons, not related to you, who you have known at least one year.

1.  Full Name:        
  Street Address:
  City: State:      Zip Code:
  Phone:        
  Length of Acquaintance:        

2.  Full Name:        
  Street Address:
  City: State:      Zip Code:
  Phone:        
  Length of Acquaintance:        

* Applicant's Statement:

I understand that any employment will be on a 90-day probationary basis and that my employment may be terminated, with or without cause or notice, at my option or that of the facility. I understand that no management representative has any authority to enter into any agreement for continued employment for any specific period of time or which is contrary to the foregoing. I give the facility permission to contact all or any of my previous employers and references and authorize them to provide all information requested of them by the facility. I authorize the facility to obtain, use and rely upon information in relation to my application. I have provided truthful and complete responses to all inquires in the application and understand that the discovery of any falsification or omission constitutes grounds for immediate dismissal. If employed by the facility, I will abide by its rules and regulations, which I understand are subject to change by the facility.

I agree with the statement. I disagree with the statement.