Lindley Health and Rehab Team

326 Lindley Lane
Newport, Arkansas 72112

Telephone 870.523.6539 Fax: 870.523.8561

Long Term Care, Rehabilitation, Hospice and Restorative Care

Thank you for your interest in employment with Lindley Health and Rehab, Inc. located in Newport, Arkansas. Below you will find our downloadable employment application which you may either mail in, or fax to: 870-523-8561

Our employment application covers all areas of need in our facility.

If you wish to fill in our online application, please do so below. Please be thorough as incomplete applications will not be considered.

DOWNLOAD OUR APPLICATION FORM
(You will need Adobe Reader to view and print)

-> PROCEED TO ONLINE APPLICATION

HELPFUL LINKS:

Online Application

Lindley Health and Rehab
***All areas must be completed or your application may be rejected***
(If assistance in the application or hiring process is needed to accommodate a disability, please advise us)

Today's Date: (IE: 7/18/2008) Expected Rate of Pay: (IE: 7.99/hr) Date Available: (IE:7/18/2008)

What position are you applying for? Other: (Please specify) Type of employment:

(This application for employment will not be considered and further processed if it is found to be incomplete)
________________________________________________________________________________________________________________________________________

Name: Social Security Number: --
First Middle Last Name

Address: Apt: City: State: Zip:

Phone: -- Alternate: -- Cell:--

Please answer the following: (All fields required)
1. Are you 18 years of age or older? YES NO (If under 18, applicant will be required to submit a certificate as required by state and federal law)
2. Do you have adequate, dependable transportation? Yes No
3. Do you have required uniforms? Yes No

____________________________________________________________________________________________________

EDUCATION:
Check the highest level or equivalence of education completed:
                  High School:9 10 11 12 College/Technical:1 2 3 4 Diploma/Degree Obtained? Yes No
                  Name and location of college, university or Vo-tech attended?

_____________________________________________________________________________________________________

BACKGROUND:
1. Have you ever been convicted of a felony? Yes No
(We complete criminal background checks on all new hires as required by Care Provider Elderly Disabled Act 990 of 1997)
2. Have you ever been disciplined, reprimanded or had legal action against you for violent behavior? Yes No
3. Have you ever been convicted or any type of theft or fraud? Yes No (If yes, identify the crime for which you were convicted. Please provide details you feel are relevant. Conviction of a crime will not automatically disqualify you from consideration for employment, but will be considered as a part of an overall evaluation of your qualifications.

(1000 character maximum)

___________________________________________________________________________________________

EMPLOYMENT HISTORY:
Starting with your present employer, list your entire employment history. For any unemployed or self-employed periods, show dates and location.

Dates of Employment
From to

Name and address of Employer:

Phone:

Position:

Supervisor's Name:

Last Rate of Pay: $ /hr

Reason for leaving:

Date of Employment
From to

Name and address of Employer:

Phone:

Position:

Supervisor's Name:

Last Rate of Pay: $/hr

Reason for leaving:

Date of Employment
From to

Name and address of Employer:

Phone:

Position:

Supervisor's Name:

Last Rate of Pay: $/hr

Reason for leaving:

If currently employed, may we contact your current employer? Yes No

_____________________________________________________________________________________________________________

REFERENCE:
List 3 people (no relatives please), with whom you have worked or have known, as it relates to your work history.

1. Name:

Occupation:

Address:

Phone:

2. Name:

Occupation:

Address:

Phone:

3. Name:

Occupation:

Address:

Phone:

________________________________________________________________________________________________

AVAILABILITY:
Please check your availability times: Sunday Monday Tuesday Wednesday Thursday Friday Anytime

________________________________________________________________________________________________

IMPORTANT (Please read carefully)
We are glad you are interested in joining us in this important work. Please read the following statement carefully before you submit this application.

The company, in considering my application for employment, may verify the information set forth on this application and obtain additional background information where legal relating to my background. I authorize all persons, schools, employers, companies, corporations, credit bureaus, CAN Registry, OLTC Employment registry and law enforcement agencies to supply any information concerning my background. I HAVE READ AND UNDERSTAND AND AGREE TO THIS STATEMENT. Please place your initials in the box.

I certify that the information on this application is correct, and I UNDERSTAND that any misrepresentation or omission of any information will result in my disqualification from consideration for employment or if employed, my dismissal. I understand that this application is not a contract, offer, or promise of employment, and if hired, I will be able to resign at any time for any reason. Likewise, the facility can terminate my employment at anytime without reason. I further understand that no one has the authority to enter into an employment contract or agreement with me, and that my at-will employment can be changed only by a written agreement by the Administrator.
I have read and understand and agree to this statement: (Please place your initials here)

I understand that this application is good for only 60 (sixty) days from today's date. If I still desire a position with the company after this application expires, it will be my responsibility to fill out a new application and return it here. Otherwise, the company will not consider me for employment after this application expires.

(Please type your full name)