Get documents about "Westminster Street Providence Rhode Island www providenceschools org CERTIFIED NURSING
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797 Westminster Street. Providence. Rhode Island. 02903-4045. 456-9100. www.providenceschools.org
CERTIFIED NURSING ASSISTANT (CNA) APPLICATION
I. PERSONAL INFORMATION
Name: _________________________ ___________________________ ____________________
Last First Middle
Maiden Name (If applicable) _________________________________
Present Address: _________________________ ___________________ _________ ________
Street City State Zip
Telephone: ___________________ Date of Birth __________________ SS# ______________
Have you ever been convicted of any offense, felony, or misdemeanor?
(Exclude traffic violation fines of less than $25.00) _____ Yes _____ No
If yes, explain fully: ______________________________________________________________
_______________________________________________________________________________
Have you ever been dismissed or asked to resign from any position? _____ Yes _____ No
If yes, explain fully: ______________________________________________________________
_______________________________________________________________________________
II. EDUCATION AND TRAINING:
List high school attended, college, or any other training which might be applicable, in chronological order.
Dates Date of
Name of School Address Attended Graduation Degree of Certification
THE PROVIDENCE SCHOOL DEPARTMENT IS AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION
EMPLOYER. THIS POSITION WILL BE FILLED WITHOUT REGARD TO RELIGIOUS PREFERENCE,
RACE, NATIONAL ORIGIN, SEX, SEXUAL ORIENTATION OR DISABILITY.
III. WORK EXPERIENCE:
Give a complete record of your full-time work experience. Indicate most recent experience at top of page, followed
by previous experience in chronological order. (Part-time experience may be included if you feel it is applicable.)
The back page of this application may be used if additional space is needed.
1.
From: To:
_________________ ___________________ _______________________ _______________________
Month/Year Month/Year Title of Position Salary/Wage
Name of Employer Duties
Address
Name of Supervisor Reason for Leaving
2.
From: To:
_________________ ___________________ _______________________ _______________________
Month/Year Month/Year Title of Position Salary/Wage
Name of Employer Duties
Address
Name of Supervisor Reason for Leaving
3.
From: To:
_________________ ___________________ _______________________ _______________________
Month/Year Month/Year Title of Position Salary/Wage
Name of Employer Duties
Address
Name of Supervisor Reason for Leaving
4.
From: To:
_________________ ___________________ _______________________ _______________________
Month/Year Month/Year Title of Position Salary/Wage
Name of Employer Duties
Address
Name of Supervisor Reason for Leaving
5.
From: To:
_________________ ___________________ _______________________ _______________________
Month/Year Month/Year Title of Position Salary/Wage
Name of Employer Duties
Address
Name of Supervisor Reason for Leaving
PROFESSIONAL REFERENCES:
Please list three references that may furnish us with pertinent information concerning your training and/or
experience.
Name Address Position
1.
2.
3.
IV. CHARACTER REFERENCES:
Please list three references that may furnish us with pertinent information concerning your character.
Name Address Position
1.
2.
3.
V. AUTHORIZATION AND SIGNATURE:
I HEREBY AUTHORIZE THE Providence School Department to obtain from my former employer(s) dates needed
to support this application. I certify that all statements made on this application are true and complete to the best of
my knowledge and that any false statements will subject me to disqualification or dismissal.
Signature: ________________________________________ Date: ______________________
NOTE: All correspondence or questions concerning applications or positions should be directed to:
Mr. Dennis Sidoti, Employee Relations Supervisor
Providence School Department, 797 Westminster Street, Providence, RI 02903.
Providence School Department
797 Westminster Street
Providence, RI 02903
Office of Human Resources
CONFIDENTIAL REFERENCE REQUEST
I grant permission for the release any and all information, as requested by the
Providence School Department, for the purposes of employment verification and
background investigation.
_____________________________ _____________ ____________________
Name Date of Birth Social Security Number
_________________________________________________________________
Applicant’s Signature
_______________________________________
Date
THE PROVIDENCE SCHOOL DEPARTMENT IS AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER.
THIS POSITION WILL BE FILLED WITHOUT REGARD TO RELIGIOUS PREFERENCE, RACE, NATIONAL ORIGIN,
SEX, SEXUAL ORIENTATION OR DISABILITY.
PRO√IDENCE SCHOOL DEPARTMENT
.
EEO/AFFIRMATIVE ACTION OFFICE
David Cicilline
Mayor
Thomas M. Brady
Superintendent
Tomás E. Ramirez, Ph.D.
Assistant Superintendent for Human Resources
And Labor Relations
Gail B. Hareld
Human Resource Administrator
Joyce O’Connor
EEO/Affirmative Action Officer
EQUAL EMPLOYMENT OPPORTUNITY SURVEY
The Providence School Department is required by the Equal Employment Opportunity
Commission (EEOC) to collect and maintain certain information in support of our Equal
Employment Opportunity Program.
THE INFORMATION REQUESTED ON THIS SURVEY IS STRICTLY FOR RECORD
KEEPING PURPOSES ONLY.
Any information you provide will be kept strictly confidential and will not be used in any hiring
decisions, failure to complete this survey will in no way prejudice the consideration of your
employment
NAME_______________________________________________________________________
LAST FIRST MIDDLE
ADDRESS____________________________________________________________________
# STREET CITY/STATE ZIP
TELEPHONE_______________
SEX: RACE:
_____ MALE _______ BLACK ________ HISPANIC
________WHITE
_____ FEMALE _______ AMERICAN INDIAN/ALASKAN NATIVE
_______ ASIAN/PACIFIC ISLANDER ________ OTHER
_____________________________________________________________________________
SIGNATURE DATE
If you qualify for consideration under our Affirmative Action Plan as a disabled person, a Vietnam Era Veteran or a
Disabled Veteran, please provide the following information
VETERAN STATUS: DISABLED:
8/5/64 - 5/7/75 _______ __________
797 Westminster Street. Providence. Rhode Island. 02903-4045. (401) 456-9222.
THE PROVIDENCE SCHOOL DEPARTMENT IS AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER. THIS
POSITION WILL BE FILLED WITHOUT REGARD TO RELIGIOUS PREFERENCE, RACE, NATIONAL ORIGIN, SEX, SEXUAL
ORIENTATION OR DISABILITY
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