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Employment Application

Thank you for your interest in growing your career with us! We pride ourselves on being the area's top employer in the senior living industry. We look forward to learning more about you!

* denotes a required field.
Personal Background
What position are you applying for?: *
First Name: *
Last Name: *
Social Security Number: *
Address: *
City: *
State: *
Postal Code: *
Phone: *
Email: *
How did you hear about us?:  
Are you under 18?: *
Type of employment desired?: *
Date available to begin work?: *
In mm/dd/yyyy format
Driver's License #: *
State driver's license was issued?: *
Additional Information
Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as the date of the offense, seriousness of nature of the violation, rehabilitation, and position applied for will be taken into account.
Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?: *
Are there currently any criminal charges pending against you, or are you under investigation for child or dependent adult abuse?: *
If you answered yes to the above question, explain:  
Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime other than a simple misdemeanor offense relating to motor vehicles and laws in this State?: *
If you answered yes to the above question, explain:  
Have you ever been or are you currently excluded or debarred from participation in any Federal or State healthcare program, including Medicare and Medicaid?: *
If yes, please indicate applicable dates/reasons:  
Employment Background
Have you ever been employed here before?: *
Have you worked for any of the facilities listed?:  
Check if yes.  
 
Employment Background Info
Starting with your most recent employer, provide the following information:
Employer Name:  
Employer phone:  
Employer Address:  
City:  
State:  
Postal Code:  
Position Held:  
Employed from:  
In mm/dd/yyyy format
Date employed to:  
In mm/dd/yyyy format
Compensation when you left.:  
Supervisors name:  
May we contact them for a reference?:  
Why did you leave?:  
Summarize the type of work performed and job responsibilities:  
What did you like most about your position?:  
What were things you liked least about this position?:  
Employer Name:  
Employer phone:  
Employer Address:  
City:  
State:  
Postal Code:  
Position Held:  
Employed from:  
In mm/dd/yyyy format
Date employed to:  
In mm/dd/yyyy format
Compensation when you left.:  
Supervisors name:  
May we contact them for a reference?:  
Why did you leave?:  
Summarize the type of work performed and job responsibilities:  
What did you like most about your position?:  
What were things you liked least about this position?:  
Employer Name:  
Employer phone:  
Employer Address:  
City:  
State:  
Postal Code:  
Position Held:  
Employed from:  
In mm/dd/yyyy format
Date employed to:  
In mm/dd/yyyy format
Compensation when you left.:  
Supervisors name:  
May we contact them for a reference?:  
Why did you leave?:  
Summarize the type of work performed and job responsibilities:  
What did you like most about your position?:  
What were things you liked least about this position?:  
Educational Background
Starting with your most recent school attended, provide the following information:
School:  
State:  
# of years completed:  
Completed:  
Comments:  
Major:  
Skills and Qualifications Info:  
Summarize any special training, skills, licenses, and/or certificates that may assist you in performing the position for which you are applying.  
School:  
State:  
# of years completed:  
Completed:  
Comments:  
Major:  
Skills and Qualifications Info:  
Summarize any special training, skills, licenses, and/or certificates that may assist you in performing the position for which you are applying.  
References
References
List the name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references.
Reference 1 Name: *
Title: *
Relationship to you: *
Phone: *
Reference 2 Name: *
Title: *
Relationship to you: *
Phone: *
Reference 3 Name: *
Title: *
Relationship to you: *
Phone: *
Resume:  
You are welcome to upload your resume here.  
(doc,docx,pdf)
Applicant Statement
By clicking this box, I'm acknowledging that I have read the following statement carefully and agree: *
Applicant statement
I certify that the answers given in the Application for Employment are true and complete to the best of my knowledge. The facility may investigate all statements made in the application, including any criminal or abuse record. I understand that any false or misleading information provided, or failure to provide information, can result in the decision not to hire, immediate discharge if hired, and civil or criminal penalties in appropriate cases. In submitting this application, I understand that I will be required to fulfill all aspects of any job if I am hired to perform the job. I understand that the failure to fulfill any aspect of the job may be grounds for termination. I also understand that I may be required to pass an agility test. I also understand that I may be required to take a physical examination conducted by a physician of the employer’s choosing after I am given a qualified offer of employment. I understand that this application is not a contract of employment; that if hired, regardless of any oral representations to the contract, the employment relationship between myself and the facility is terminable at will; that I have the right to terminate my employment at any time for any reason, and the facility retains the same right. Any changes to this employment relationship must be in writing. I understand that if I am hired I am required to abide by all rules and regulations of the facility. An Equal Opportunity Employer Applicants are considered for, and employees are treated during employment without regard to age, race, color, sex, national origin, religion, sexual orientation, disability, or status as a disabled Vietnam-era Veteran.