Full Name *

Address

Address Line 2

City and State

Zip Code

Home Phone

Cell Phone *

Email *

Upload Resume

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Are you legally eligible for employment in the U.S.A.? *

Yes No

Enter your age IF under 18 years of age:

Maiden name or other last names used

Were you previously employed by us? *

Yes No

If yes, when?

Name during employment (if different than above)

Your position during employment

Job Preferences

Position(s) applied for

Rate of pay expected

Hours and days available

If selected, on what date will you be available for work?

Shift Preference

List here any special certifications, skills, or qualifications related to this position.

Have you ever been found guilty of any crime, including DUI, other than a traffic violation? *

Yes No

If yes, list all convictions and year

Note

It is important to list any misdemeanor, felony, or juvenile adjudication on your application. Convictions are not an absolute bar to employment, but certain enumerated crimes are prohibited by the state of Kansas. Factors such as the date of conviction, seriousness and nature of the conviction will all effect the consideration for the position.

Education

Name of School & Location

Course of College Major

Years Completed

Graduate?

Yes No

Degree

Additional Education

Name of School & Location

Course of Study

Years Completed

Graduate?

Yes No

Name of School & Location

Course of Study

Years Completed

Graduate?

Yes No

Are you a veteran of the Armed Forces?

Yes No

Current nursing license and/or certifications in Kansas

License and Expiration Date

How did you hear about the position?

If referred by an employee, state the employee's name

Do you have any relatives working at Wesley Towers?

Yes No

If yes, list name and relationship

Work History

Employer (current or most recent)

Employer Phone (Enter N/A if unknown) *

Salary Per Hour / Title & Duties

Name of Supervisor

Total Hours Per Week

From Month / Year

To Month / Year

Reason for Leaving

Employer 2

Employer 2 Phone (Enter N/A if unknown)

Salary Per Hour / Title & Duties

Name of Supervisor

Total Hours Per Week

From Month / Year

To Month / Year

Reason for Leaving

Employer 3

Employer 3 Phone (Enter N/A if unknown)

Salary Per Hour / Title & Duties

Name of Supervisor

Total Hours Per Week

From Month / Year

To Month / Year

Reason for Leaving

May we contact your PRESENT employer for references?

Yes No

Abuse Neglect Exploitation Crime

Have you been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law or have a crime against a person (i.e., battery) or theft in the last five years? *

Yes No

Have you had a finding entered at the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property? *

Yes No

Have you had a disciplinary action in effect against your professional license by a state licensure body as a result of abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property? *

Yes No

If you answered yes to any of these three questions, you are not eligible to work at Wesley Towers.

Personal References (Not former employers or relatives)

Reference 1 Name and Occupation *

Reference 1 Address *

Reference 1 Phone Number *

Reference 1 Relationship and Years Known *

Reference 2 Name and Occupation *

Reference 2 Address *

Reference 2 Phone Number *

Reference 2 Relationship and Years Known *

Reference 3 Name and Occupation *

Reference 3 Address *

Reference 3 Phone Number *

Reference 3 Relationship and Years Known *

Release of Information

Wesley Towers is an "at-will" employer. This means that your employment with Wesley Towers is based on mutual consent and both Wesley Towers and the employee have the right to terminate employment at any time with or without cause or justification and with or without notice. Wesley Towers does not sign or recognize contracts of employment.
I understand that as a condition of my consideration for employment, Wesley Towers may obtain a consumer report that includes, but is not limited to, employment and education verifications, social security verification, criminal and civil history, personal interviews, DMV records, Medicare fraud, any other public records and any other information bearing on my character, general reputation, personal characteristics and trustworthiness.
I understand that all offers of employment from Wesley Towers are contingent on passing the drug/alcohol screening and pre-employment physical (if applicable). Any contingent offer of employment will be withdrawn if the applicant tests positive for any illegal drugs/alcohol, does not pass the pre-employment physical or fails to disclose all or prohibited convictions on background checks. I affirm that I have given true and complete information on this application. I have also read, understand, and accept the conditions of employment stated on this application and further authorize the release of information as stated above. I understand that false information or omissions on this application, including failure to list all past employers for the past 10 years may result in the rejection of this application or may be grounds for dismissal if discovered at a later date. I understand that a photocopy of this signed release will also serve as effective and valid as the original. By electronically filling out your name and date in the below boxes, you hereby acknowledge having read the above disclosure and procedures of Wesley Towers and agree to follow the above requirements:

Your Full Name (Electronic Signature) *

Date *

By using this form you agree with the storage and handling of your data by this website. *

General Application

Apply for Employment

Job Preferences

Note

Education

Additional Education

Current nursing license and/or certifications in Kansas

Work History

Abuse Neglect Exploitation Crime

If you answered yes to any of these three questions, you are not eligible to work at Wesley Towers.

Personal References (Not former employers or relatives)

Release of Information