Careers – Mary Scott Nursing Center

Find us on Facebook

Call Today

(937) 278-0761

Application for Employment

Would you like to work at Mary Scott Nursing Center? We are looking for dedicated, caring workers to join our family.

Our Mission – “To provide health care that enriches the Quality of life for the aging, Special needs populations, and their families.”

If our mission fits your work goals please fill out the form below and we will contact you!

Red Asterisks are Required Fields *

I understand that I am to fill in all spaces on this application honestly and to the best of my knowledge

Date *

Name *

First

Last

Email *

Address - Street, City, Zip *

Contact Number *

Position(s) Desired *

Hours

Part-Time
Full-Time

Which Shift

First Shift
Second Shift
Third Shift

Date You Can Start

Are you currently employed?

Level of Education Completed

How did you hear about Mary Scott Nursing Center?

Did someone refer you to Mary Scott Nursing Center?

Single Line Text

Are you at least 18 years of age or older?

Are you a legal resident of the US?

Have you ever been convicted of a misdemeanor or felony?

If yes, please explain

Have you been convicted of a traffic violation in the past three years?

If yes, please explain

Past Employer Information Name & Address of Most Recent Employer

Annual Salary

Dates of Employment From (dd/mm/yr) to (dd/mm/yr)

Name of Supervisor

Contact Number

May we contact this employer?

Reason for Leaving

Description of Work Performed

Name & Address of Second Most Recent Employer

Annual Salary

Dates of Employment From (dd/mm/yr) to (dd/mm/yr)

Name of Supervisor

Contact Number

May we contact this employer?

Reason for Leaving

Description of Work Performed

Name & Address of Third Most Recent Employer

Annual Salary

Dates of Employment From (dd/mm/yr) to (dd/mm/yr))

Name of Supervisor

Contact Number

May we contact this employer?

Reason for Leaving

Description of Work Performed

Please give name, phone number and relationship of three (3) persons who are not related to you that you have known for more than 1 year

CERTIFIED SIGNATURE AND INFORMATION RELEASE I HEREBY CERTIFY THAT THE STATEMENTS CONTAINED IN THIS APPLICATION OR OTHER DOCUMENTS SUBMITTED AND THE STATEMENTS MADE DURING ANY INTERVIEW PROCESS ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE, AND I UNDERSTAND THAT MATERIAL OMISSIONS FROM OR FALSE STATEMENTS MADE IN THIS APPLICATION OR OTHER DOCUMENTS SUBMITTED OR OCCURRING DURING ANY INTERVIEW PROCESS SHALL BE GROUNDS FOR DENIAL OF EMPLOYMENT OR TERMINATION IF EMPLOYED AT THE TIME. I ALSO VOLUNTARILY CONSENT AND SUBMIT TO AND AUTHORIZE MARY SCOTT NURSING CENTER THROUGH A PHYSICIAN CHOSEN BY IT TO CONDUCT AT PRE-EMPLOYMENT OFFER AND FUTURE PHYSICAL/MEDICAL EXAMINATIONS INCLUDING DRUG AND ALCOHOL SCREENING TEST AND THAT FAILURE TO PASS SUCH TEST(S) IN WHOLE OR IN PART, WILL BE GROUNDS FOR DENIAL OF EMPLOYMENT OR TERMINATION IF EMPLOYED AT THE TIME. I UNDERSTAND THAT STATE LAW, AM SUB. S.B.160, REQUIRES CANDIDATES WHO RECEIVE FINAL CONSIDERATION FOR CERTAIN POSITIONS IN NURSING HOMES, RESIDENTIAL CARE FACILITY, HOMES FOR THE AGAIN, SKILLED NURSING FACILITIES AND SIMILAR AGENCIES TO UNDERGO A CRIMINAL RECORD CHECK AND THAT INDIVIDUALS WHO HAVE BEEN CONVICTED OR PLEAD GUILTY TO PROHIBITED OFFENSES SPECIFIED IN THE LAW, AM SUB. S.B.160, MAY BE DISQUALIFIED FOR EMPLOYMENT IN COVERED AGENCIES. SHOULD I RECEIVE FINAL CONSIDERATION FOR EMPLOYMENT, I CONSENT AND VOLUNTARILY SUBMIT TO PROVIDING FINGERPRINT IMPRESSIONS, A VALID “CERTIFICATE OF NO RECORD”, AND OTHER INFORMATION WHICH MAY BE REQUIRED TO DETERMINE MY ELIGIBILITY FOR EMPLOYMENT UNDER AM SUB. S.B.160. I UNDERSTAND AND AGREE THAT NOTHING STATED IN THIS EMPLOYMENT APPLICATION, IN ANY OTHER DOCUMENT, OR IN ANY INTERVIEW IS INTENDED TO CREATE AN EMPLOYMENT CONTRACT BETWEEN MARY SCOTT NURSING CENTER AND MYSELF FOR EITHER EMPLOYMENT OR FOR PROVIDING ANY BENEFIT. LIKEWISE, NO SUCH CONTRACTS ARE INTENDED TO BE CREATED FROM THE MERE GRANTING OF AN INTERVIEW. NO PROMISES OR GUARANTEES REGARDING EMPLOYMENT HAVE BEEN MADE TO ME, AND I UNDERSTAND THAT NO SUCH PROMISE OR GUARANTEE IS BINDING UPON MARY SCOTT NURSING CENTER UNLESS MADE IN WRITING BY THE EXECUTIVE DIRECTOR OR DESIGNEE, AND THEN ONLY FOR THE TIME SPECIFIED OR, IN NONE IS SPECIFIED, ONE WEEK. I UNDERSTAND AND AGREE THAT IF I AM HIRED; MY EMPLOYMENT IS FOR NO DEFINITE PERIOD OF TIME. I FURTHER UNDERSTAND AND AGREE THAT, REGARDLESS OF THE DATE OF THE PAYMENT OF WAGES, SALARY OR BENEFITS, MY EMPLOYMENT, INCLUDING WAGES, SALARY OR BENEFITS MAY BE TERMINATED WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE AT ANY TIME BY MARY SCOTT NURSING CENTER. IN ADDITION, I UNDERSTAND THAT I LIKEWISE MAY TERMINATE MY EMPLOYMENT WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE AT ANY TIME. SIGNATURE OF APPLICANT FILLING IN WITH NAME AND DATE IS AN ELECTRONIC SIGNATURE

TO WHOM IT MAY CONCERN: I AUTHORIZE AND REQUEST EACH FORMER EMPLOYER AND EACH PERSON, FIRM OR CORPORATION WHICH I HAVE GIVEN AS A REFERENCE, EACH SCHOOL, COLLEGE, OR UNIVERSITY WHICH I HAVE INDICATED; ALL LOCAL, MUNICIPAL, CITY, COUNTY, STATE, AND FEDERAL LAW ENFORCEMENT AUTHORITIES TO FURNISH ANY INFORMATION THAT MAY BE SOUGHT BY MARY SCOTT NURSING CENTER CONCERNING ME; AND I HEREBY RELEASE ALL PARTIES FROM ANY LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING ANY SUCH INFORMATION AND WAIVE ANY PRIVILEGES INVOLVED. SIGNATURE OF APPLICANT FILLING IN WITH NAME AND DATE IS AN ELECTRONIC SIGNATURE

PLEASE LIST ANY OTHER NAMES THAT RECORDS MAY BE LISTED UNDER (I.E. MAIDEN NAME)

APPLICANT STATEMENT/ CERTIFICATION RELATED TO PROHIBITED OFFENSES (FORM 2.18A) PLEASE INDICATE BY CHECKING EITHER YES OR NO, IF YOU HAVE BEEN CONVICTED OF OR PLEAD GUILTY TO ANY THE PROHIBITED OFFENSES LISTED BELOW:

AGGRAVATED MURDER OR MURDER

VOLUNTARY/INVOLUNTARY MANSLAUGHTER

ASSAULT OR FELONIOUS ASSAULT

FAILING TO PROVIDE FOR A FUNCTIONALLY IMPAIRED PERSON

AGGRAVATED MENACING

ABUSE OR NEGLECT OF A PATIENT

KIDNAPPING

ABDUCTION

EXTORTION

COERCION

RAPE

SEXUAL BATTERY

GROSS SEXUAL IMPOSITION

IMPORTUNING

VOYEURISM

PUBLIC IMPOSITION

FELONIOUS PENETRATION

PROSTITUTION

DISSEMINATING MATTER HARMFUL TO MINORS

PANDERING OBSCENITY

PANDERING OBSCENITY INVOLVING A MINOR

PANDERING SEXUALLY ORIENTED MATTER INVOLVING A MINOR

ILLEGAL USE OF A MINOR A NUDITY-ORIENTED MATERIAL OR PERFORMANCE

AGGRAVATED ROBBERY

ROBBERY

AGGRAVATED BURGLARY

BURGLARY

BREAKING AND ENTERING

THEFT

UNAUTHORIZED USE OF A VEHICLE

UNAUTHORIZED USE OF PROPERTY

PASSING BAD CHECKS

MISUSE OF CREDIT CARD

FORGERY

MEDICAID FRAUD

SECURING WRITING BY DECEPTION

INSURANCE FRAUD

RECEIVING STOLEN PROPERTY

DOMESTIC VIOLENCE

ILLEGAL CONVEYANCE OF WEAPON OR OTHER PROHIBITED ITEMS ONTO THE GROUNDS OF DETENTION, MENTAL HEALTH OR MENTAL RETARDATION FACILITY

CARRY A CONCEALED WEAPONS

HAVING WEAPON WHILE UNDER DISABILITY

IMPROPERLY DISCHARGING A FIREARM AT OR INTO A SCHOOL OR HOUSE

CORRUPTING ANOTHER WITH DRUG

AGGRAVATED TRAFFICKING

TRAFFICKING DRUGS

TRAFFICKING MARIJUANA

DRUG ABUSE

PERMITTING DRUG ABUSE

DECEPTION TO OBTAIN DANGEROUS DRUGS

ILLEGAL PROCESSING DRUGS DOCUMENTS

PLACING HARMFUL OBJECTS IN OR ADULTERATING FOOD OR CONFECTION

I understand that this applicant statement/certification related to prohibited offenses will be used in conjunction with criminal records check to determine my eligibility for employment at Mary Scott Nursing Center. I certify that by my answering yes or no, I have indicated if I have been convicted of, or plead guilty to any of the prohibited offenses listed above. SIGNATURE OF APPLICANT FILLING IN WITH NAME AND DATE IS AN ELECTRONIC SIGNATURE