Pulaski Health Care Center

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Rehabilitation Services

 

 

Our Team

 

Application for Employment

Please fill out this form, click Submit and we will contact you. Fields with a * are required.

• PERSONAL INFORMATION

  Your Name * First Middle Initial Last
• Your Address *
  Street Address
  Address Line 2
  City
  State
  Zip Code
• Your Phone * - (###) - ### ####
• Your Email Address
• Are you at least 18 years of age?
  Yes No
• Professional License Number
  License Type
• If you are not a U.S. citizen, do you have the legal right to remain permanently and work in the U.S.?
  Yes No

• EMPLOYMENT DESIRED

• Position You Are Applying For
• Shift(s) You Can Work
  Days Evenings Nights Any
• Date you can start
• Type of Work
  Full Time Part Time

• EDUCATION

• Highest level of education you have completed?
  Name of last school attended?
  Degree attained?
  Vocational or trade training?

• REFERENCES

  List below three people not related to you.

• REFERENCE #1: Name First Last Address
  Street Address
  Address Line 2
  City
  State
  Zip Code
  Phone Number - (###) - ### #### Email Address
  In what capacity do you know this person?
• REFERENCE #2: Name First Last Address
  Street Address
  Address Line 2
  City
  State
  Zip Code
  Phone Number - (###) - ### #### Email Address
  In what capacity do you know this person?
• REFERENCE #3: Name First Last Address
  Street Address
  Address Line 2
  City
  State
  Zip Code
  Phone Number - (###) - ### #### Email Address
  In what capacity do you know this person?

• WORK EXPERIENCE

  List below your work experience, starting with your present or last place of employment.

• EMPLOYMENT #1: Dates of Employment Start Date End Date Name of Company
  Address
  Street Address
  Address Line 2
  City
  State
  Zip Code
  Phone Number - (###) - ### #### Supervisor's Name Position Held Reason for Leaving
• EMPLOYMENT #2: Dates of Employment Start Date End Date Name of Company
  Address
  Street Address
  Address Line 2
  City
  State
  Zip Code
  Phone Number - (###) - ### #### Supervisor's Name Position Held Reason for Leaving
• EMPLOYMENT #3: Dates of Employment Start Date End Date Name of Company
  Address
  Street Address
  Address Line 2
  City
  State
  Zip Code
  Phone Number - (###) - ### #### Supervisor's Name Position Held Reason for Leaving
• Additional Comments
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Get Directions

Contact Information

Pulaski Health Care Center
624 E 13th St
Winamac, IN 46996

Tel: 574-946-3394
Fax: 574-946-4923

Pulaski Health Care Center does not discriminate against any person on the basis of race, color, national origin, disability, or age in admission, treatment, or participation in its programs, services and activities, or in employment. For further info about our non-discrimination policy, contact: Sharon McKinley/Section 504 Coordinator. 574-946-3394