Full application form is available here (PDF format)
 
Online Pre-Employment Application
1

PERSONAL INFORMATION

Name
  (Last) (Middle) (First)
Address
Street
City State
Zip Code    
Telephone E-Mail
       
Position(s) applying for: Rate of Pay desired:
Available to work: Full-Time Part Time
Shift Preference: 1st 2nd 3rd Rotating
Will you work different shifts? Yes No
Are you currently employed? Yes No
Date available to start work?
Check the facilities you are interested in working at:
Alois Alzheimer Center
Brookwood Retirement Community
Clovernook Health Care Pavilion
Loveland Health Care Center
Florence Park Care Center
2

PROFESSIONAL LICENSE AND/OR CERTIFICATIONS

Are you currently: Accredited Certified Licensed
Registered have an Interim Permit
License/Certification State of Issuance Licensing Agency Expiration Date Number
If issuing state is not Ohio, have you applied for reciprocity? Yes No
Has your professional license ever been revoked, suspended, or subject to any disciplinary action?
Yes No
If yes, list where, for what, and give dates:
3

EDUCATIONAL BACKGROUND

Type of School Name Course of Study Did you graduate? List Degree or Diploma
High School
College
Business or Trade
Other
4

PREVIOUS WORK EXPERIENCE
(List last four positions held – list most recent first)

Name of Employer:
Address:
City:
State:
Zip:
Telephone No.:
Job Duties:
Reason for Leaving:
Dates of Employment:
From to
Ending Salary:
Supervisor’s Name:
Name Worked Under:
Name of Employer:
Address:
City:
State:
Zip:
Telephone No.:
Job Duties:
Reason for Leaving:
Dates of Employment:
From to
Ending Salary:
Supervisor’s Name:
Name Worked Under:
5

Submit your pre-employment
application!
This Pre-Employment Application is an initial screening of candidates interested in our employment opportunities.
If you appear to have the skills and experience needed for our current vacancies we will be contacting you.



The Health Care Management Group
12100 Reed Hartman Hwy.
Cincinnati, OH 45241
Phone: (513) 605-2700
Fax: (513) 489-2408
Email: info@hcmg.com


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