Canton (770) 720-0290 | Ellijay (706) 515-4100

Personal Information
Date: Facility Location: 
Please make a selection.
Name: (Last, First)
Name is required.		 Social Security: 
Address: Address Is Required.
City:
City is required.		 State: 
State is required.  Zip: 
Zip is required.
Phone Number:
Phone is required.		 Referred by: 
Email Address: Email is required.Invalid format.
Are you over age 18? Yes  No Are you over age 21? Yes  No
Have you ever been convicted of a felony? Yes  No
Are you willing to take a drug test? Yes  No

 

Employment Desired
Position: Caregiver  Cook  Activities  Maintenance  Administrative  Other 
Shift Preference:  7:00 a.m. - 3:00 p.m.   3:00 p.m. - 11:00 p.m.   11:00 p.m. - 7:00 a.m. Make at least one selection. .
Date you can start: A start date is required.
Salary desired:
Are you employed? Yes  No May we contact your employer? Yes  No

Ever applied to this company before?

Yes  No If so, when? 

 

Education History
  Name and Location of School Years Attended Graduated? Subjects Studied
Middle School:
Required.
Required.		 Yes  No
High School:
Required.
Required.		 Yes  No
College: Yes  No
Additional Schools: Yes  No
Employment History

List four former employers, starting with your most recent employment:

Company Name: Required. Telephone:  Required.
Start Date: Required. End Date: Required.
Job Title: Required. Salary: Required.
Reason for Leaving:
Required.

Company Name: Telephone: 
Start Date: End Date: 
Job Title: Salary: 
Reason for Leaving: 

Company Name: Telephone: 
Start Date: End Date: 
Job Title: Salary: 
Reason for Leaving: 

Company Name: Telephone: 
Start Date: End Date: 
Job Title: Salary: 
Reason for Leaving: 
References

List three persons not related to you, whom you have known at least one year:

Name:
Required.		 Address: 
Telephone: 
Required.		 Business: 
Years Known:
Required.Invalid format.
 
Name:
Required.		 Address: 
Telephone:
Required.		 Business: 
Years Known:
Required.Invalid format.
 
Name:
Required.		 Address: 
Telephone:
Required.		 Business: 
Years Known:
Required.Invalid format.

APPLICANT CERTIFICATION & AUTHORIZATION "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal." "I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that they may result from utilization of such information." "I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative."

Date:  Required.   Signature (type name):  Required.

Anti-spam: What is 8 plus 4? Wrong.Wrong. Wrong.Wrong.

 

Cameron Hall has two convenient locations in north Georgia.

Canton Residence
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Ellijay Residence
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