Employment — Mountain View Manor

Position Applying For

Staff Nurse

CNA

Dietary

Housekeeping

Laundry

Maintenance

Activities

Social Work

Bookkeeper

Receptionist

Admin. Asst.

PCA

First Name*

Last Name*

Email*

Phone*

Address

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

Shift Preferred

1st

2nd

3rd

Would you accept full time or part time work?

Full time

Part time

NOTE: Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation, and position applied for will be taken into account.

Have you ever pleaded "guilty" or "no contest" to, or been convicted of a crime?

Yes

No

If yes, please provide dates(s) and details:

Explain any gaps in your employment other than those due to illness, injury, or disability.

Have you ever been fired or asked to resign from a job?*

If yes, please explain.

Please provide at least 3 employment references. Include position held, dates employed, and contact information.*

Please provide 3 school, personal or business/non-supervisor work references (NOT INCLUDING FAMILY). Include name, telephone number, and email.*

Textarea

I certify that all the   information submitted by me on this application is true and complete; I understand that if any false or misleading information, omissions, or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time.If hired, I agree to conform to the Company's rules and regulations. I understand that these rules and/or the employee handbook do not form a contract of employment either express or implied, and I agree that my employment and compensation can be terminated, with or without cause and with or without notice at any time, at either my or the Company's option.I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the Company.I expressly authorize, without reservation, the employer, its representatives, employees, or agents to contact and obtain information from all references both personal and professional, employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees, or representatives for seeking, gathering, and using truthful and nondefamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.I understand that, if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States as required by federal immigration laws.This Company does not tolerate unlawful discrimination or harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. No question on this application is used to limit or exclude an applicant from employment consideration on any basis prohibited by applicable federal, state, or local law.

Signature*

Date*