Apply — LPN — Campbell Hall Rehabilitation Center

About you

First name *

Last name *

Email *

Phone *

Middle name

Maiden / other names

Alternate phone

Address line 1

Address line 2

City

State

Postal

Are you at least 18 years of age?

Yes No

Availability

Which shifts can you work? (check all that apply)

Day Evening Night Any

Full-time or part-time?

Date you can begin work

History with us

Have you ever applied with us before?

Yes No

Have you ever been employed with us before?

Yes No

May we contact your present employer?

Yes No

May we contact your previous employers?

Yes No

If applied: approximate date

If employed: approximate date

Background

A "yes" does not automatically disqualify you — please give us context so we can have an informed conversation.

Were you ever dismissed or discharged from any employment for reasons other than lack of work?

Yes No

Did you ever resign from any employment rather than face dismissal?

Yes No

Except for minor traffic violations and youthful-offender adjudications, have you ever been convicted of any crime?

Yes No

License / certification (if applicable)

For RN, LPN, CNA, HHA and other licensed/certified roles.

License state

License / cert number

Expiration

Other state of registration

Other state number

NYS Boards taken

Education

Leave blank rows you don't need.

Level	School name & location	Course of study	Yrs	Grad?	Degree / diploma
Elementary
High School
Business / Trade / Tech
College
Graduate

Work history

Most recent first. Leave blocks blank if you don't have three prior jobs.

Most recent

Employer

Job title

Employer address

Phone

Supervisor

From (mo / yr)

To (mo / yr)

Work performed

Reason for leaving

Job title

Employer address

Phone

Supervisor

From (mo / yr)

To (mo / yr)

Work performed

Reason for leaving

Earlier

Employer

Job title

Employer address

Phone

Supervisor

From (mo / yr)

To (mo / yr)

Work performed

Reason for leaving

References

Three people not related to you, whom you have known for at least one year.

Reference 1

Name

Relationship

Phone

Street

City

State

Zip

Reference 2

Name

Relationship

Phone

Street

City

State

Zip

Reference 3

Name

Relationship

Phone

Street

City

State

Zip

How did you hear about us?

Source

If employee referral, who?

Other (please specify)

Specialized skills (optional)

Equipment

Computer software

Foreign languages

Other skills

Anything else?

Resume

PDF, DOC, DOCX, RTF, or TXT. Up to 5 MB.

A few questions

Are you legally authorized to work in the United States?

Yes No

Do you hold an active New York State Licensed Practical Nurse (LPN) license?

Yes No

Do you have at least one year of nursing experience (hospital, long-term care, or similar clinical setting)? *

Yes No

Are you able to pass a background check, drug screen, and TB test as required by our facility?

Yes No

What is your primary reason for applying to Campbell Hall?

Cover letter (optional)

I'd like other MySNF facilities to be able to see my profile for future openings. You can change this anytime by contacting us.

Certifications & signature

Please review and check each statement. Your typed name + the timestamp + your IP address are recorded as your electronic signature.

I certify that all answers given on this application are true and complete to the best of my knowledge. I authorize the facility to verify all information on this application, including contacting my references and former employers. I release them from any liability for providing this information. I understand that any employment relationship is "at will": I may resign at any time and the employer may discharge me at any time, with or without cause, unless otherwise required by applicable law. I understand this application is active for three (3) months. After that, I must submit a new application to be considered. I understand that any falsification or willful omission on this application is sufficient cause for refusal of employment or dismissal.

Type your full name as your signature *

Date