Regency Grande Post-Acute, Rehab & Nursing Center

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  1. Regency Employment Application


    We appreciate your interest in the employment opportunities at Regency Grande Post-Acute, Rehab & Nursing Center. Our team includes professionals in Nursing (RN, LVN, CNA, RNA,) Marketing, Housekeeping, Dietary, Laundry, Maintenance, Social Services, Business Office, and Activities!

    Please inquire about current job openings. We commit to hire enthusiastic, professional and compassionate individuals who enjoy coming to work every day.

    You may use this Application for Employment form below to apply for any job.

     

    APPLICANT INFORMATION


  2. Date*
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  3. First Name / Middle Initial / Last Name*
    Please tell us your name
  4. Address*
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  5. City*
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  6. State*
    Please select one
  7. Zip*
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  8. Phone*
    Please tell us your phone number
  9. Email*
    Please tell us your email address
  10.  
  1. DESIRED EMPLOYMENT INFORMATION


  2. Date Available*
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  3. Desired Salary*
    Invalid Input
  4. Position Applying For*
    Invalid Input
  5. Are you a citizen of the United States or authorized to work in the U.S.?*
    Please select one
  6. Have You Ever Worked For This Company?*
    Please select one
  7. If Yes, When?
    Invalid Input
  8. Have You Ever Applied With This Company?*
    Please select one
  9. If Yes, When?
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  10. Are You 18 Years or Older?*
    Please select one
  11. Desired Day(s)*




    Please select one
  12. Desired Shift(s)*




    Invalid Input
  13. If You Selected Other Above, Please Tell Us What Are Your Desired Shifts?
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  14. Were You Referred by a Current Employee?*
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  15. If So, Please List Employee Name
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  16. Position
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  17. Relationship
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  18. Do You Have Any Relatives Employed by Us? *
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  19. If So, Please List Employee Name
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  20. Position
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  21. Relationship
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  22.  
  1. RESUME

    (If you have a resume you would like to upload please select file and skip to the end of the form. If you do not have a resume to upload, please continue filling out the rest of this form.)


  2. Do you have a Resume to upload*
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  3. Upload Resume
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  4.  
  1. EDUCATION

     

    High School


  2. High School
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  3. Address
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  4. Attended From
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  5. Attended To
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  6. Did you graduate?
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  7. Degree
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  8.  

    College


  9. College
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  10. Address
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  11. Attended From
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  12. Attended To
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  13. Did you graduate?
    Invalid Input
  14. Degree
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  15.  

    Other Schooling


  16. Other
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  17. Address
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  18. Attended From
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  19. Attended To
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  20. Did you graduate?
    Invalid Input
  21. Degree
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  22.  
  1. LICENSE/CERTIFICATION


  2. Do you have a State Certification or License?
    Invalid Input
  3. If yes, what type? (CNA, CMA, LPN, RN)
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  4. Issuing State
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  5. Certificate or License Number
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  6. Has your License/Certification ever been under review, revoked or suspended because of activity related to patient care or the performance of your duties in your profession?
    Invalid Input
  7. If yes, please explain
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  8.  
  1. PREVIOUS EMPLOYMENT

    List below your work experience, starting with your present or last place of employment.

    COMPANY 1


  2. Company
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  3. Phone
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  4. Address
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  5. Supervisor's Name
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  6. Job Title
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  7. Starting Salary - Ending Salary
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  8. Responsibilities
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  9. Date Started
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  10. Date Ended
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  11. Reason for Leaving
    Invalid Input
  12. May we contact your previous supervisor for a reference?
    Invalid Input
  13.  

    EMPLOYMENT #2


  14. Company
    Invalid Input
  15. Phone
    Invalid Input
  16. Address
    Invalid Input
  17. Supervisor's Name
    Invalid Input
  18. Job Title
    Invalid Input
  19. Starting Salary - Ending Salary
    Invalid Input
  20. Responsibilities
    Invalid Input
  21. Date Started
    / Invalid Input
  22. Date Ended
    / Invalid Input
  23. Reasons for Leaving
    Invalid Input
  24. May we contact your previous supervisor for a reference?
    Invalid Input
  25.  

    EMPLOYMENT #3


  26. Company
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  27. Phone
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  28. Address
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  29. Supervisor's Name
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  30. Job Title
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  31. Starting Salary - Ending Salary
    Invalid Input
  32. Responsibilities
    Invalid Input
  33. Date Started
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  34. Date Ended
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  35. Reasons for Leaving
    Invalid Input
  36. May we contact your previous supervisor for a reference?
    Invalid Input
  37.  
  1. MILITARY SERVICE


  2. Branch
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  3. Attended From
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  4. Attended To
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  5. Rank at Discharge
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  6. Type of Discharge
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  7. If other than honorable, explain:
    Invalid Input
  8.  
  1. SPECIALIZED TRAINING / SKILLS / ORGANIZATIONS


  2. Please list any specialized training or skills you have that you consider relevant to the job in which you are applying for. You may also list any professional groups or organizations you belong to.
    Invalid Input
  3.  
  1. REFERENCES

    List below three people not related to you.

    REFERENCE #1


  2. Full Name
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  3. Relationship
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  4. Company Name
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  5. Phone
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  6. Address
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  7.  

    REFERENCE #2


  8. Full Name
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  9. Relationship
    Invalid Input
  10. Company Name
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  11. Phone
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  12. Address
    Invalid Input
  13.  

    REFERENCE #3


  14. Full Name
    Invalid Input
  15. Relationship
    Invalid Input
  16. Company Name
    Invalid Input
  17. Phone
    Invalid Input
  18. Address
    Invalid Input
  19.  
  1. Disclaimer and Electronic Signature

    I Understand:

    • That completing this application does not constitute an offer of employment and that my application may be rejected for any reason.
    • That giving false or misleading information on this form or in an interview is grounds for denial or immediate termination of employment.
    • That I may be required to complete a medical history form and may be required to be examined by a medical professional designated by Regency Post-Acute, Rehab & Nursing Center.
    • That if I sustain any injury or illness in the employment of Regency Post-Acute, Rehab & Nursing Center, I agree that Regency Post-Acute, Rehab & Nursing Center shall be entitled to receive full and complete reports and records covering any medical or related exams, and I authorize any and all such doctors, medical examiners, and hospitals to give to Regency Post-Acute, Rehab & Nursing Center full and complete reports and records covering such examinations, condition, care, and treatment related to or resulting from the alleged illness or injury.
    • THAT IF HIRED MY EMPLOYMENT WILL BE "AT WILL" WHICH MEANS THAT I OR THE EMPLOYER CAN TERMINATE MY EMPLOYMENT FOR ANY OR NO REASON WITH OR WITHOUT NOTICE

    Authorization to Release Information:

    If I am given a conditional offer of employment, I authorize Regency Post-Acute, Rehab & Nursing Center to make a complete investigation of me, including but not limited to: my past employment history, medical history, scholastic records, criminal records, abuse records, motor vehicle driving records, workers’ compensation history and to rely on such information sources. I authorize all persons and organizations to release any information concerning my background and hereby release all persons and organizations from liability for any damage whatsoever for issuing this information. I acknowledge that a telephone facsimile (fax) or photographic copy shall be as valid as the original.

    By checking below, I certify that I have not been convicted of an offense that would preclude working in a nursing facility. I also certify that I am not excluded from participation in federal health care programs. Furthermore, I understand that I will be subject to a search of the OIG List of Excluded Individuals, and that a comprehensive criminal background screening will be completed by a third party organization acting on behalf of Regency Post-Acute, Rehab & Nursing Center. If the findings of that background screening result in a refusal to hire, I will be notified in writing and may request a copy of the findings from the third party organization.

    I understand that the use of illegal drugs is prohibited during employment. If employment policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and/or during employment.

    I understand that this employment application and any other employee-related documents are not contracts of employment; and that any individual who is hired may voluntarily leave employment upon proper notice, and may be terminated by the employer at any time for any reason. I understand that any oral or written statements to the contrary are hereby expressly disavowed and should not be relied upon by any prospective or existing employee.

    I certify that my answers are true and complete to the best of my knowledge.

    If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

  2. Please Read and Approve The Information Above by Checking Below*
    Please authorize that you have read and approve the information above.

  3. Enter The Code*
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Regency Grande Post-Acute, Rehab & Nursing Center
65 North Sussex Street, Dover, NJ 07801
Tel: (973) 361-5200 Fax: (973) 361-0375 Email Us

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