Online Application Form
Position Applied For?
ACTIVITIES
Activity Aide
Activity Volunteer
DIETARY
Cook
Dishwasher
Server
HEALTH SERVICES
Certified Nursing Assistant (CNA)
Licensed Practical Nurse (LPN)
Med Tech (Already Certified in PA)
Resident Care Aide (RCA)
OPERATIONS
Housekeeper
Laundry Aide
Maintenance Worker
Painter
SECURITY
Security Guard
OTHER
Other (Please Specify Below)
STATE
•Pennsylvania - PA
•Alabama - AL
•Alaska - AK
•Arizona - AZ
•Arkansas - AR
•California - CA
•Colorado - CO
•Connecticut - CT
•Delaware - DE
•Florida - FL
•Georgia - GA
•Hawaii - HI
•Idaho - ID
•Illinois - IL
•Indiana - IN
•Iowa - IA
•Kansas - KS
•Kentucky - KY
•Louisiana - LA
•Maine - ME
•Maryland - MD
•Massachusetts - MA
•Michigan - MI
•Minnesota - MN
•Mississippi - MS
•Missouri - MO
•Montana - MT
•Nebraska - NE
•Nevada - NV
•New Hampshire - NH
•New Jersey - NJ
•New Mexico - NM
•New York - NY
•North Carolina - NC
•North Dakota - ND
•Ohio - OH
•Oklahoma - OK
•Oregon - OR
•Rhode Island - RI
•South Carolina - SC
•South Dakota - SD
•Tennessee - TN
•Texas - TX
•Utah - UT
•Vermont - VT
•Virginia - VA
•Washington - WA
•West Virginia - WV
•Wisconsin - WI
•Wyoming - WY
SHIFT
Daylight (7 AM-3 PM)
Evening (3 PM-11 PM)
Midshift (11 AM-7 PM)
Overnight (11 PM-7 AM)
HOURS
Full-Time
Part-Time
Shift Work
Temporary
2200 W Liberty Ave
Pittsburgh, PA 15226
Ph. 412-344-9915
Fax 412-344-3551
YES
NO
If you are under 18 years of age, can you provide proof of work eligibility?
YES
NO
Have you ever applied with us before? (If YES, on what date?)
YES
NO
Have you ever been employed with us before? (If YES, on what date?)
YES
NO
When would you be able to start?
Are you currently employed?
If you are currently unemployed, what have you been doing since your last job?
Have you ever been discharged or asked to resign from a job? (If yes, please explain)
YES
NO
HIGH SCHOOL
COLLEGE/TRADE
GRADUATE/
PROFESSIONAL
Degree Earned
Master's
Doctorate
LPN
Nurse Practioner
RN
Level Completed
Diploma
GED
Did not finish
Degree Earned
Associate's
Bachelor's
I did not complete
Ended
Began
Ended
Ended
Began
Began
If you did not graduate what was the reason?
Fair Oaks is a SMOKE-FREE & DRUG-FREE community!
We have a ZERO TOLERANCE policy for drug use while employed.
EDUCATIONAL BACKGROUND
Type of reference?
Personal
Professional
End
End
End
Start
Start
Start
Type of reference?
Personal
Professional
Type of reference?
Personal
Professional
WORK HISTORY & EXPERIENCE
REFERENCES