Application Name* First Last Address* Street Address Address Line 2 City State Zip Phone*How did you hear about us* Our Website Job Fair Job Board Friend Walk-in Social Media Other Date Available to Start* MM slash DD slash YYYY If Applicable, List licenses and certificates held. (Example: CNA, RN, LPN, ect)If Applicable, List licenses and certificates held. (Example: CNA, RN, LPN, ect)If hired, can you furnish proof that you are eligible to work in the United States?* Yes No Are you excluded from working at a company that participates in the Medicare, Medicaid, or other federal health care programs; or have you been placed on the Office of Inspector General’s List of Excluded Individuals?* Yes No I consent to Parks Place employees checking my qualifications, references, and relevant background. I waive any claim I might ever have against Parks Place, its employees, and its directors, relating to the receipt, use, or disclosure of information any of them receive from others in the course of legitimate business activities.* Yes No I understand that any offer of employment I receive will be conditional on passing a background check, references, other pre-employment screening, and a drug test (at sites where required).* Yes No Email* Resume*Accepted file types: pdf, doc, docx, Max. file size: 20 MB.Please attach a resume. Accepted file types include PDF, DOC, DOCX of size 20MB or less.I verify the information provided on this application is true and correct to the best of my knowledge.* EmailThis field is for validation purposes and should be left unchanged.