Employment Application 1234567 APPLICANT INFORMATION Please provide complete and legible information. An incomplete application may affect your consideration for employment. If necessary, attach a separate sheet for additional information. We are committed to a policy of equal employment opportunity and will not discriminate against an applicant or employee on the basis of age, sex, sexual orientation, gender identity, race, color, creed, religion, ethnicity, national origin, citizenship, disability, marital status, military status, pregnancy, or any other legally-recognized protected basis under federal, state or local laws, regulations, or ordinances. Applicants with disabilities may be entitled to reasonable accommodation. A reasonable accommodation is a change in the way things are normally done that will ensure an equal employment opportunity without imposing an undue hardship on the organization. Please inform us if you need assistance completing any forms or to otherwise participate in the application process. * Hampshire Manor is a tobacco/smoke-free work environment. Policy prohibits employees from smoking anywhere on any Hampshire Manor property.First* Last* Middle Current Address* City* State* Zip Code* Email Address Phone Number* GENERAL INFORMATIONPosition Applying For Type of Work Full Time Part Time Salary Desired Date Available To Start Shift Preferance Day Night Any Evening Weekend Are you at least 18 years old? Yes No Are You Willing to Work Overtime? Yes No Do you have a reliable means of transportation to get to work? Yes No Are there any times during the week that you are not available to work? Yes No If so, please explain:Have you ever worked for this company? Yes No If yes, when and where?Have you ever applied to this company? Yes No If yes, when and where?Do you know anyone who works for this company? Yes No If yes, please identify:Do you have a valid Driver's License? (Only for jobs where driving a vehicle is an essential function) Yes No How did you hear about us? Newspaper Ad Employee Referral Community Agency Open House Internet Ad School Recruiting Walk-in Recruiting Agency Job Fair CNA Program/School Are you legally authorized to work in the United States? Yes No To comply with the Immigration Reform and Control Act, if you are hired you will be required to provide documents to establish your identity and your authorization to work in the United States. WORK EXPERIENCE List Most Recent Work Experience First)EMPLOYMENT #1Employer Name: Address: Starting Position: Position Duties and Skills:From: To: Ending Position: Reason for Leaving:Phone Number: Supervisor Name and Title: EMPLOYMENT #2Employer Name: Address: Starting Position: Position Duties and Skills:From: To: Ending Position: Reason for Leaving:Phone Number: Supervisor Name and Title: EMPLOYMENT #3Employer Name: Address: Starting Position: Position Duties and Skills:From: To: Ending Position: Reason for Leaving:Phone Number: Supervisor Name and Title: May we contact your current or last employer listed above? Yes No Use this space or the back of the application to summarize any other employment-related to this job including military service assignments and volunteer activities. EDUCATIONHigh School Name: High School Address: Years Completed: Field of Study: Graduate or Degree: College UniversityCollege/University Name: College/University Address: Years Completed: Field of Study: Graduate or Degree: Graduate SchoolGraduate School Name: Graduate Address: Years Completed: Field of Study: Graduate or Degree: Other (Business, Technical, Secretarial)Institution Name: Institution Address: Years Completed: Field of Study: Graduate or Degree: SKILLS AND QUALIFICATIONSOther qualifications such as special skills, abilities or honors that should be considered:Types of computer software or applications you are qualified to operate:Professional licenses, certifications or registrations:Additional skills including supervision skills, other languages or information regarding the career/occupation you wish to bring to the employer’s attention:Typing Speed: Please enter words per minute. REFERENCES List two personal references who are not relatives or former supervisors. Name: Phone: Occupation: Years Known: Name: Phone: Occupation: Years Known: ContactIn case of accident or illness please contact: Name: Phone: Address: Relationship: Background RecordHave you ever had your professional license suspended, revoked or restricted? Yes No If yes, please explain:Have you ever had a severe citation (A or AA) or deficiency (G or IJ tags) as National Health Administrator or Executive Director in any state? Yes No If yes, please explain:Have you ever been convicted of a crime, whether a felony or a misdemeanor? (Conviction includes a please of guilty, nolo contendere, no contest, or a finding of guilty by a court or jury.) Yes No Do not answer “Yes” or provide any information regarding convictions if any of the following applies: - The conviction occurred in juvenile court; - A court sealed, expunged, dismissed or otherwise removed the conviction from your record; - The law changed, which results in the elimination of your conviction (the conviction was statutorily eradicated); - You participated in a pre-trial or post-trial diversion program that resulted in dismissal of the conviction; - The conviction was a misdemeanor relating to possession of marijuana and the conviction is two or more years old.Is there a pending, non-juvenile criminal charge against you for which you are currently out on bail or on your own recognizance pending trial? Yes No If you answered “Yes” to the questions above, please explain below. A conviction, or pending charge, will not necessarily disqualify you from employment. Each conviction or pending charge will be evaluated on its own merits with respect to time, circumstances and seriousness in relation to the job applied for. However, certain state laws may bar your employment. AUTHORIZATION AND ACKNOWLEDGMENT I hereby certify that all of the information in this application is complete and accurate to the best of my knowledge and belief. I understand and agree that any omissions or false or inaccurate statement in my application or interview may be justification for refusal to hire or termination of employment if I am hired, regardless of the time lapse until discovery. (Initial)I hereby authorize the company and/or its representatives to investigate all references, to contact all prior employers and to secure additional information about me concerning my qualifications for the position applied for. I hereby release from liability the Company and its representatives for seeking such information. (Initial)I hereby authorize all prior employers, schools, credit bureaus, Social Security Administration, law enforcement agencies, consumer reporting agencies, investigative companies and any other persons, companies or governmental or other agencies to give the Company any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, concerning my qualifications for the position applied for. I release all persons or entities from all liability for any damage or injury that may result from furnishing information to the Company. I also release the Company and all of its employees from all liability for any damage or injury that may result from reliance on the information furnished. (Initial)I understand and agree that nothing contained in this application packet or in the hiring process is intended to create or does create an employment contract. I understand that no representation, whether oral or written by any representative or agent of the Company, at any time, can constitute an implied or express contract of employment. I understand and agree that if hired my employment is at-will, and therefore, my employment can terminate, with or without cause, at any time at my option or the option of the Company. (Initial)I acknowledge that any offer of employment with the Company is conditional upon passing the Company’s health screening. The health screening includes the completion a Post-Offer Pre-Employment Health Questionnaire along with a physical exam and passing the test of a urine sample to determine the presence of certain drugs and/or alcohol in the body. (Initial)No offer of employment with the Company is final until a prospective employee has passed a criminal background check. I understand that fingerprinting and criminal history investigations for employees are required by law and company policy in order for the community to maintain its licenses with governmental entities. I also understand that prior to the commencement of any employment with the Company and, if I am employed, during my employment with the Company, my fingerprints may be required and an investigation into my criminal history may be conducted pursuant to the applicable laws and requirements. With this understanding, I knowingly and voluntarily consent to the use of my fingerprints and criminal history by the Company or any governmental entity for employment and licensing purposes. (Initial)Further, I authorize any law enforcement agency (federal, state or local) to provide any record or information concerning my criminal history to the Company or any governmental entity for such purposes. (Initial)The Company reserves the right to conduct searches on Company property or of the Company’s property, vehicles and/or equipment at any time. I further understand that if I refuse to submit to a Company search, I may be terminated. (Initial)I understand and agree that this application will remain active for 90 days. If I still want to be considered for a position with the Company after this application expires, it is my responsibility to complete a new application. (Initial)Applicant Signature By signing your full legal name, this counts as your legal signature.Date ResumeAccepted file types: pdf, Max. file size: 64 MB.Please attach your resume here. Only PDF files will be accepted at this time. Thank you!CAPTCHA4 + 2 = __* PhoneThis field is for validation purposes and should be left unchanged.