Job Application

Name

I am 21 years of age or older: Yes No

I have a valid Driver's License: Yes No

Application will remain on file for 3 months. After 3 months, you may reapply.

Address

Street

City/State

Zip

Primary Phone

Secondary Phone

Alternate Phone

Positions

Child Care Therapy Office Administrative Maintenance Kitchen Housekeeping Intern

Are you a:

Prior Applicant First Time Applicant Former Employee

Check shifts & days you are able to work.

Shift	Mon	Tue	Wed	Thur	Fri	Sat	Sun
6am-2pm
2pm-10pm
10pm-6am

Availability is not an assurance of shift assignment should you be employed.

The greater your availability, the greater your employability.

Are you related to an employee of the Carmelite Home?

Yes No

Name of Relative

Were you referred by an employee? If so, what is there name?

Yes No

Name of Employee

Are you related to a current resident of the Carmelite Home?

Yes No

Number of Hours per Week Desired

Would you work overtime hours?

Yes No

Are you willing to work other shifts if needed?

Rotating On Call Any Time Substitute

Your current or most recent hourly rate of pay

Employment History

Present Employer

Position

Date Started

Employer

Supervisor

Address

Street

City/State

Zip

Phone

Fax

May we contact your present employer?

Prior Employer 1

Position

Date Started

Date Ended

Employer

Supervisor

Address

Street

City/State

Zip

Phone

Fax

Reason for Leaving

May we contact your previous employer?

Prior Employer 2

Position

Date Started

Date Ended

Employer

Supervisor

Address

Street

City/State

Zip

Phone

Fax

Reason for Leaving

May we contact your previous employer?

Prior Employer 3

Position

Date Started

Date Ended

Employer

Supervisor

Address

Street

City/State

Zip

Phone

Fax

Reason for Leaving

May we contact your previous employer?

Prior Employer 4

Position

Date Started

Date Ended

Employer

Supervisor

Address

Street

City/State

Zip

Phone

Fax

Reason for Leaving

May we contact your previous employer?

Education

High School

Name

Address

Street

City/State

Zip

Did you receive a Diploma?

Type of Degree

Graduation Year

College

Name

Address

Street

City/State

Zip

Did you receive a Diploma?

Type of Degree

Graduation Year

Other Education

Name

Address

Street

City/State

Zip

Did you receive a Diploma?

Type of Degree

Graduation Year

In case of an emergency, please notify:

Name

Relationship

Phone Number

I certify that answers given herein are true and complete. I understand that misrepresentation or omission is cause for immediate dismissal regardless of when discovered. Furthermore, I authorize investigation of all statements contained in this application. I further authorize permission for the Carmelite Home to conduct criminal history background checks and to contact the references I have provided on the attached forms.

I have carefully reviewed and understand this entire application, including the above statement.

Signature

Date

Authorization for Release of Information

I hereby grant St. Josephʼs Carmelite Home permission to request and obtain references or other pertinent information needed for possible employment. I also release all parties from any liability or responsibility in granting and furnishing such information.

Signature

Date

Information Requested By Human Resources Department St. Josephʼs Carmelite Home/Holy Innocents Center

4840 Grasselli Avenue
East Chicago, IN 46312

stjoecarmelite@gmail.com

Phone 219-397-1085 Fax 219-392-3575

The St. Josephʼs Carmelite Home is an equal opportunity employer

Join Our Staff

Current Needs

In addition to needed dollars, suggested perfume free, hypoallergenic/unscented items include:

Eatery Gift Cards Ex: McDonald's, Burger King, Wendy's, Taco Bell
Shopping Gift Cards Ex: Walmart, Target, Visa
Body Wash, Shampoo, Conditioner
Latex Powder Free Gloves-Large Size
Bottles of Hand Sanitizer & Sanitizing Wipes
Lysol Spray & Lysol Sanitizing Wipes
Tide Laundry Detergent
18 Gallon Bins With Lids
Call 219.397.1085 for additional inquiries

All items dropped off at the Carmelite Home are best delivered to 4840 Grasselli in East Chicago at the front door between the hours of 10am and 2pm. Monday through Friday to be documented.

100% of donations supports services

Job Application

Employment History

Education

Authorization for Release of Information

Current Needs

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