Job Application

Join the GoltryCare Nursing Agency Team

At GoltryCare Nursing Agency, we are always looking for dedicated and skilled nursing professionals to join our team. If you are passionate about providing exceptional care and are seeking rewarding career opportunities, we invite you to apply with us.

To ensure a smooth application process, please review the following documentation requirements. Having these documents ready will expedite your application and help us match you with the best opportunities.

Additional Documentation Requirements

Physical (current within a year)
1 step TB test (current within a year)
CPR
Driver License or State ID
Covid Status
Nursing License (RN/LPN only)

Available for download

For your convenience, the following forms are available for download. Please complete these forms and submit them along with your application:

APPLICATION FORM

PERSONAL INFORMATION

LAST NAME

MIDDLE NAME

LAST NAME

POSITION

REFERRED BY

SOCIAL SECURITY NUMBER

TYPE OF EMPLOYMENT

EMAIL ADDRESS

SHIFT DESIRED

HOME ADDRESS

CITY

STATE

ZIP CODE

HOME PHONE

EMERGENCY CONTACT NAME

ARE YOU ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES?

DO YOU HAVE VALID DRIVER'S LICENSE?

HAVE YOU EVER SERVED IN THE US MILITARY?

CAN YOU LIFT, TURN AND MOVE PATIENTS?

DO YOU HAVE A HIGH SCHOOL DIPLOMA OR EQUIVALENT?

CELL PHONE

PHONE NUMBER

ARE YOU 18 YEARS OF AGE OR OLDER?

DO YOU HAVE FRIENDS OR RELATIVE EMPLOYED BY GOLTRYCARE?

HAVE YOU EVER BEEN CONVICTED OF ANY LAWS OTHER THAN MINOR TRAFFIC VIOLATIONS?

APPLICATION CONFIDENTIALITY STATEMENT

Please read each statement carefully before signing

I understand that this application is not a promise of employment. I understand that if I am hired, my employment will be for no definite period, regardless of the period of payment of wages. If accepted for employment, I agree to abide by all policies and procedures. I further understand that I have the right to terminate my employment at any time with or without notice, and GoltryCare has the same right. No one other than the Executive Director of GoltryCare has the authority to modify this relationship or make any agreement to the contrary. Any such notification or agreement must be in writing.

I understand that employment by GoltryCare and the signing of this statement does NOT constitute a contract of employment or guarantee employment for specific length of time.

I understand that the company will investigate criminal background record and may investigate my driving record. As a part of the hiring process, GoltryCare will be checking references. GoltryCare may ask questions relating to work experience and opinions that are useful in making hiring decision. GoltryCare may contact the references listed and may contact past employers and other named in this application to ask any questions relating to work experience and opinions useful to hiring decision. I authorize and release those employers to disclose to the company all records regarding my employment with them. I agree to release this person from legal liability in providing a statement.

APPLICANT NAME

DATE

EMPLOYMENT HISTORY

- EMPLOYER 1 -

FIRST EMPLOYER

DATE

ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

ENDING PAY RATE

SUPERVISOR NAME AND TITLE

STARTING PAY RATE

TITLE/DUTIES

REASON FOR LEAVING

- EMPLOYER 2 -

FIRST EMPLOYER

DATE EMPLOYED

ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

SUPERVISOR NAME AND TITLE

ENDING PAY RATE

STARTING PAY RATE

TITLE/DUTIES

REASON FOR LEAVING

- EMPLOYER 3 -

FIRST EMPLOYER

DATE EMPLOYED

ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

ENDING PAY RATE

SUPERVISOR NAME AND TITLE

STARTING PAY RATE

TITLE/DUTIES

REASON FOR LEAVING

EDUCATION RECORD

- HIGH SCHOOL -

NAME

CITY

STATE

YEAR GRADUATED

- BUSINESS OR TECHNICAL SCHOOL -

NAME

CITY

STATE

YEAR GRADUATED

- UNDERGRADUATE COLLEGE -

NAME

CITY

STATE

YEAR GRADUATED

- GRADUATE SCHOOL -

NAME

CITY

STATE

YEAR GRADUATED

- EMPLOYMENT AGREEMENT -

APPLICANT NAME

DATE

- EMPLOYEE HANDBOOK -

I have received a copy of GoltryCare employee handbook and will follow the policies during my employment with this agency.

APPLICANT NAME

DATE

- POSITION DESCRIPTION -

I have received a copy of the position description for my personal records and I understand that it is my responsibility to read and understand the agencies position description.

APPLICANT NAME

DATE

- RESIDENT RIGHTS -

I have received a copy of the Resident Rights for long term care facilities and In Home Client Rights. I understand their right and will abide by them.

APPLICANT NAME

DATE

EMPLOYMENT REFERENCE LETTER

- REREFERENCE LETTER 2 -

DATE

PHONE NUMBER

APPLICANT NAME

SOCIAL SECURITY NUMBER

- WAS EMPLOYED -

FROM

IN THE POSITION OF

REASON FOR LEAVING

I authorize you to release any and all employment reference information.

APPLICANT NAME

- REREFERENCE LETTER 2 -

DATE

PHONE NUMBER

APPLICANT NAME

SOCIAL SECURITY NUMBER

- WAS EMPLOYED -

FROM

IN THE POSITION OF

REASON FOR LEAVING

I authorize you to release any and all employment reference information.

APPLICANT NAME

- FACILITY CALL OFF POLICY -

As stated in our contracts per facility agency employees attempting to call off less than 2 hours to the start of a shift will have 2 hours deducted from your pay check due to late call in.

I have read and understand the call in policy.

EMPLOYEE NAME

DATE

UPLOAD FILE HERE (accepted file formats: .doc, .docx, .pdf | max: 10mb)

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Illinois, Georgia, Iowa, Indiana, Florida, Texas, New York, Arkansas, Arizona, and California

Job Application

Join the GoltryCare Nursing Agency Team

Additional Documentation Requirements

Available for download

PERSONAL INFORMATION

APPLICATION CONFIDENTIALITY STATEMENT

EMPLOYMENT HISTORY

- EMPLOYER 1 -

- EMPLOYER 2 -

- EMPLOYER 3 -

EDUCATION RECORD

- HIGH SCHOOL -

- BUSINESS OR TECHNICAL SCHOOL -

- UNDERGRADUATE COLLEGE -

- GRADUATE SCHOOL -

- EMPLOYMENT AGREEMENT -

- EMPLOYEE HANDBOOK -

- POSITION DESCRIPTION -

- RESIDENT RIGHTS -

EMPLOYMENT REFERENCE LETTER

- REREFERENCE LETTER 2 -

- WAS EMPLOYED -

- REREFERENCE LETTER 2 -

- WAS EMPLOYED -

- FACILITY CALL OFF POLICY -

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