Employee Application Form - Rivers Edge Assisted Living

Name *

First

Last

Present Address *

City, State, Zip Code

Permanent Address *

City, State, Zip Code

Phone Number *

Email Address *

Are you 18 years of age or older? *

Have you applied at this company before? *

If yes, when?

Position Desired *

Date Available to Work *

Salary Desired *

Are you employed? *

If so, may we contact your present employer?

Are you legally eligable to work in the United States? *

Referred By

Temporary Agency
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Employee
Other

Employee's Name

If referred by employee.

High School Education *

Name of High School and Years Attended

Did you graduate *

College Education

Name of College, Years Attended, and Subjects Studied

Did you graduate

Other

List any other education you've received, years attended, and subjects studied.

Licenses or Awards that Apply to Application

List any licenses, awards, certifications, or registrations pertinent to your application.

Employment 1 *

Name, Address, and Phone Number of Employer

Dates Employed with the Above *

List to and from dates (month/year) from when you were employed or list Present if you're still working there.

Position *

Supervisor's Name *

Salary *

Reason for Leaving *

Employment 2 *

Name, Address, and Phone Number of Employer

Dates Employed with the Above *

List to and from dates (month/year) from when you were employed or list Present if you're still working there.

Position *

Supervisor's Name *

Salary *

Reason for Leaving *

Employment 3

Name, Address, and Phone Number of Employer

Dates Employed with the Above

List to and from dates (month/year) from when you were employed or list Present if you're still working there.

Position

Supervisor's Name

Salary

Reason for Leaving

Employment 4

Name, Address, and Phone Number of Employer

Dates Employed with the Above

List to and from dates (month/year) from when you were employed or list Present if you're still working there.

Position

Supervisor's Name

Salary

Reason for Leaving

Reference 1 *

Relationship and Title *

Refer to Reference 1

Company Name and Address *

Refer to Reference 1

Telephone Number *

Refer to Reference 1

Reference 2 *

Relationship and Title *

Refer to Reference 2

Company Name and Address *

Refer to Reference 2

Telephone Number *

Refer to Reference 2

Reference 3

Relationship and Title

Refer to Reference 3

Company Name and Address

Refer to Reference 3

Telephone Number

Refer to Reference 3

Additional Information

Please list any other job-related information you think would be helpful to us in considering you for the position, such as any additional work experience, volunteer activities, hobbies, social activities, clubs or professional organizations (list offices held), publications, accomplishments, etc. (Exclude information indicative of race, color, religion, sex, age, marital status, national origin, disability, or veteran status.)

Acknowledgement *

I Accept

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. I authorize investigation of all statements contained in this application (and accompanying resume, if any) as may be necessary in arriving at an employment decision. I authorize any persons, schools, current or previous employers, and organizations named in this application form (and accompanying resume, if any) to provide Rivers Edge Assisted Living (the “Company”) with relevant information and opinion that may be useful to the Company in making a hiring decision, and I release such persons and organizations from any legal liability in making such statements. I authorize the Company and/or its agents including consumer reporting bureaus to release any information regarding my background. I understand that employment at Rivers Edge Assisted Living is on an at-will basis, and that my employment can be terminated, with or without cause, with or without notice, at any time at the discretion of either the Company or myself. I understand that no management official other than the Managing Partner(s)/Owners of the Company have any authority to enter into any agreement contrary to the foregoing or make any oral assurance or promise of continued employment. This application is not intended to create, nor is it to be construed to constitute a contract between Rivers Edge Assisted Living and myself. I am willing to undergo a background check in accordance with local law/regulations. I understand, also, that I am required to abide by all rules and regulations of the Company. In accordance with the Company’s policy to maintain a drug-free workplace, I understand that any offer of employment may be contingent upon submitting to a drug test and receiving a negative test result. Further, I understand certain employees may be subject to drug testing throughout their employment. I hereby agree to drug testing as required by the Company and release Company from all liability arising from such testing and/or decisions made based on such testing. Should an offer of employment be made and accepted, I will be required to provide proper documentation of legal right to work in the United States as required by the Immigration Reform and Control Act of 1986. If documents are not produced within three days of date of hire, employment will terminate. Receipt of this application (and accompanying resume, if any) does not mean that a job opening exists at Rivers Edge Assisted Living and does not obligate Rivers Edge Assisted Living in any way. This application (and accompanying resume, if any) is valid for one year. I acknowledge that I have read and understand this agreement, have signed this release voluntarily and of my own free will.

Name (Electronic Signature) *

Date of Application (Today's Date) *