Employment Application

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Your Personal Information

Your Name:

First Middle Last

All other last names, if applicable:

Your Email Address:

Enter Email Confirm Email

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone:

Home Phone:

Best Time To Call You

When is the best time for us to reach you via telephone?

ADDRESS HISTORY

Please provide address history for previous seven (7) years.

Address 1:

Street Address Address Line 2 City State ZIP Code

Number of Years at Address 1:

Address 2:

Street Address Address Line 2 City State ZIP Code

Number of Years at Address 2:

Address 3:

Street Address Address Line 2 City State ZIP Code

Number of Years at Address 3:

Address 4:

Street Address Address Line 2 City State ZIP Code

Number of Years at Address 4:

Address 5:

Street Address Address Line 2 City State ZIP Code

Number of Years at Address 5:

Address 6:

Street Address Address Line 2 City State ZIP Code

Number of Years at Address 6:

POSITION INFORMATION/REQUESTS

Position(s) Applying For:

Salary Request:

Shift(s) Request:

11PM-7AM

7AM-3PM

3PM-11PM

Other

Specify Other Time Frame If Selected:

Status Request:

Full-Time

Part-Time

PRN

REFERRAL INFORMATION

Referral Source:

Employment Agency

Friend

Walk In

Other

Relative

If referred by current employee, please list his/her name here:

Questions

Have you completed an application for employment here before?

Yes

If yes, when:

Have you been employed by our company before?

Yes

If yes, when:

Are you related to anyone who is an employee of the facility?

Yes

If yes, who:

What date are you available for work?

MM slash DD slash YYYY

If you are under 18 years of age, do you have a work permit?

Yes

Not Applicable

Upon employment, can you furnish proof of your legal right to work in the United States?

Yes

Do you have a valid state driver's license?

(Only applicable if required for the job)

Yes

EMPLOYMENT HISTORY

List your last FIVE employers, starting with the current or most recent first. Summarize the nature of the work performed and job responsibilities. ALL INFORMATION MUST BE COMPLETED ON THIS SHEET.

Employer 1's Name:

Employer 1's Phone:

Employer 1 Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Title:

Status:

Full Time

Part Time

Per Diem

Employed From:

MM slash DD slash YYYY

To:

MM slash DD slash YYYY

Hourly Rate/Salary Starting:

Hourly Rate/Salary Ending:

If still employed, may we contact?

Yes

Reason for leaving:

Immediate Supervisor/Title:

Summary of Responsibilities:

Employer 2's Name:

Employer 2 Phone:

Employer 2 Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Title:

Status:

Full Time

Part Time

Per Diem

Employed From:

MM slash DD slash YYYY

To:

MM slash DD slash YYYY

Hourly Rate/Salary Starting:

Hourly Rate/Salary Ending:

If still employed, may we contact?

Yes

Reason for leaving:

Immediate Supervisor/Title:

Summary of Responsibilities:

Employer 3's Name:

Employer 3 Phone:

Employer 3 Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Title:

Status:

Full Time

Part Time

Per Diem

From:

MM slash DD slash YYYY

To:

MM slash DD slash YYYY

Hourly Rate/Salary Starting:

Hourly Rate/Salary Ending:

If still employed, may we contact?

Yes

Reason for leaving:

Immediate Supervisor/Title:

Summary of Responsibilities:

Employer 4's Name:

Employer 4 Phone:

Employer 4 Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Title:

Status:

Full Time

Part Time

Per Diem

Employed From:

MM slash DD slash YYYY

To:

MM slash DD slash YYYY

Hourly Rate/Salary Starting:

Hourly Rate/Salary Ending:

If still employed, may we contact?

Yes

Reason for leaving:

Summary of Responsibilities:

Employer 5's Name:

Employer 5 Phone:

Employer 5 Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Title:

Status:

Full Time

Part Time

Per Diem

Employed From:

MM slash DD slash YYYY

To:

MM slash DD slash YYYY

Hourly Rate/Salary Starting:

Hourly Rate/Salary Ending:

If yes, please describe in full detail:

Yes

Reason for leaving:

Immediate Supervisor/Title:

Summary of Responsibilities:

EDUCATION

High School Name/Address of School:

Did you graduate?

Yes

Date Degree Expected:

MM slash DD slash YYYY

GPA

College Name/Address of School:

College Major or Degree:

Did you graduate?

Yes

Date Degree Expected:

MM slash DD slash YYYY

GPA

Graduate School Name/Address of School:

Graduate School Major or Degree:

Did you graduate?

Yes

Date Degree Expected:

MM slash DD slash YYYY

GPA

Trade/Other Training School Name/Address of School:

Trade School Major or Degree:

Did you graduate?

Yes

Date Degree Expected:

MM slash DD slash YYYY

GPA

PROFESSIONAL LICENSES/CERTIFICATES

License/Certificate Information

Type

License/Certification #

Date Issued

Issued by Organization/State

Exp Date

Specialized Skills/Knowledge:

Include knowledge/use of equipment operated such as medical terminology, computer skills, and software, etc.

PROFESSIONAL REFERENCES

Reference 1 Name

Company Name and Address

Telephone/Email

Professional Relationship

Supervisor

Colleague

Other

Reference 2 Name

Company Name and Address

Telephone/Email

Professional Relationship

Supervisor

Colleague

Other

Reference 3 Name

Company Name and Address

Telephone/Email

BACKGROUND INFORMATION

Have you ever been convicted of a felony or pled guilty or no contest to a felony?

Yes

If yes, please describe in full detail:

Have you ever been discharged, suspended, or asked to resign from any position?

Yes

If yes, please describe in full detail:

Upload Your Resume

Upload your resume in .pdf, .doc or .docx format

Accepted file types: pdf, doc, docx, Max. file size: 25 MB.

Upload Your Cover Letter

Accepted file types: pdf, doc, docx, Max. file size: 25 MB.

APPLICANT’S CERTIFICATION – Please read carefully before signing

I hereby certify that all answers on this application are true and correct to the best of my knowledge and belief. I understand that any misrepresentation will be considered just cause for rejection of this application or dismissal from employment. I understand and agree that, if employed, such employment may be terminated at any time, without prior notice, and that my employment will not be governed by any expressed or implied contract, but is at will. Upon termination of my employment, I authorize the release of reference information concerning my work.

I authorize my current and former employers, educational institutions, governmental agencies, references and others named in this application and accompanying documents, if any, to disclose any and all information and opinions about me that may be lawfully disclosed.

I acknowledge that Twin Creeks Assisted Living and Memory Care maintains a drug free workplace and may require applicants to undergo urinalysis screening for drug or alcohol use as part of a pre-placement review. A pre-placement physical exam may be required, and/or drug testing. I authorize the test results to be released to the Medical Review Officer or designated supervisor/manager on a need-to-know basis. I acknowledge that refusing to submit to such screening will cause my application for employment to be rejected. In addition, all employees of the company may be subject to random urinalysis screening for drug or alcohol use.

The company is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, age, sex, religion, national origin, handicap, marital status, veteran status, medical condition, disability or any other legally protected status. We assure you that your opportunity for employment depends solely upon your qualifications.

If employed, I agree to comply with all company policies, practices, and safety guidelines. I will report all suspected violations related thereto, and will conduct the Company’s business in a strictly ethical, professional, and legal manner. I understand and agree that all programs, benefits, policies and practices of the Company may be subject to exceptions or change at any time, with or without notice, as determined by the Company.

Terms and Conditions(Required)

I agree to the terms and conditions.