THE ALVERNO Employment Application

Please Print

Date of Application______Position Desired______

Name______

(Last) (First) (Middle)

Street Address______City______State_____ Zip______

Phone ( )______Cell Phone ( )______E-mail Address______

Please circle the appropriate answer

Are you at least 18 years of age? Yes No

Are you at least 16 years of age? Yes No (If less than age 16, can you furnish a work permit? Yes No )

Are you employed now? Yes No May we contact your present employer? Yes No

Are you on a layoff and subject to recall? Yes No

Have you ever been employed here before? Yes No If so, give date______

(Previous Name)

Are you legally eligible for employment in the United States? Yes No

If hired, you will be required to submit documents sufficient to establish employment authorization and identify compliance with the Immigration Reform and Control Act of 1986. While you need not provide this proof of citizenship or immigration status at the time you are interviewed, please be prepared to assure us that you can do so immediately upon being hired.

If applying for Nursing Assistant, are you on a state registry as a CNA? Yes No In what state:______

Shift preference: Day Evening Night

Are you willing to work weekends? Yes No Holidays? Yes No Desired Salary______

When are you available to begin work?______

Are you available for full-time work? Yes No If not, what hours can you work?______

Have you ever been terminated because of suspicion of dependent adult abuse? Yes No

Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a rime other than a simple misdemeanor offense relating to motor vehicles and laws of the road under chapter 321 or equivalent provisions, in this state or any other state? Yes No

If so, explain: ______

______

Are there currently any criminal charges pending involving you, or are you under investigation for child or dependent adult abuse?

Yes No

If so, explain: ______

______

How did you learn of opening?______

EDUCATION

Name & Address of School / Course of Study / Circle Last Year Completed / Did You Graduate? / List Degree or Diploma
High School / 1 2 3 4 / Yes No
College / 1 2 3 4 / Yes No
Other / Yes No

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include military service assignments and/or volunteer activities. Account for all periods of unemployment. Exclude organization names which indicate, for example, race, color, religion, sex, national origin or disability.

Name of Employer / Address / Phone Number / Date of Employment
From To
Job Title / Supervisor / Salary
Starting Final / Reason for Leaving
Work Performed
Name of Employer / Address / Phone Number / Date of Employment
From To
Job Title / Supervisor / Salary
Starting Final / Reason for Leaving
Work Performed
Name of Employer / Address / Phone Number / Date of Employment
From To
Job Title / Supervisor / Salary
Starting Final / Reason for Leaving
Work Performed
Professional References
Reference Name, Title and Company Worked With
/ Area Code and Telephone Number(s)

Special skills and qualifications, including those acquired from employment or other experience______

______

______

Educational Honors: Extra Curricular Activities; Professional Societies or other information (if unrelated to ethnic or religious groups or organizations):______

______

If you need additional space, please continue on a separate sheet of paper.

APPLICANT'S STATEMENT

PLEASE READ CAREFULLY BEFORE SIGNING

I certify that the answers given in this Application for Employment are true and complete to the best of my knowledge. The facility may investigate all statements made in this Application. The facility is required by law to check for any criminal or abuse record. I understand that any false or misleading information provided can result in a decision not to hire; immediate discharge if hired, and civil or criminal penalties in appropriate cases.

In signing this Application I state that I have received a copy of the Job Description for all jobs for which I have applied. I under-stand 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 result in termination. I also understand that I may berequired to take a physical examination conducted by a physician of the employer’s choosing after I am given a qualified offer of employment and that ahealth screening for diseases, such as TB, is required.

I understand that this application is not a contract of employment; that if hired, regardless of any oral representations to the contrary, 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 hired I am required to abide by all rules and regulations of the facility.

______

Signature of Applicant Date

An Equal Opportunity Employer

This facility is an equal opportunity employer. Employment decisions are made without regard to age, race, creed, color, sex, sexual orientation, gender identity, national origin, religion, disability, status as a disabled Vietnam era veteran, or other category as specified by law.

ADMAPP Common\Office\Word\Forms\Application – Page 1- 6/03; Rev. 11/04; 2/27/08; 3/25/08; 9/17/09; 5/31/11; 5/2/12

THE ALVERNO

PROSPECTIVE EMPLOYEE AUTHORIZATION

I (the “applicant”) understand the information in this application will be used and that prior employers may be contacted for verification of employment information.

It is agreed and understood that the employer, or its agents, may verify the applicant’s background (including criminal background checks which require the applicant’s date of birth, education confirmation, reference checks, and name/social security number link), to ascertain any and all information concerning the applicant’s record, whether same is of record or not, and the applicant releases employers and persons named herein from all liability for any damages on account of his/her furnishing such information.

I also understand that, as a part of the application process, The Alverno will verify with state(s) Nurse and nurse aide registry my competence and certification as a Registered or Licensed Nurse and/or nurse aide (if applicable) and may obtain any and all information contained in the registry for use in evaluating my application for employment.

The applicant agrees to furnish additional information that may be needed in the employment process related to his/her skills, abilities and qualifications. This information will be used in evaluating your employment status.

It is also understood that The Alverno has pets and a pet therapy program which may expose me to different animals at the Facility (i.e., birds, cats, dogs).

It is agreed and understood that this application for employment in no way obligates the employer to employ the applicant.

I voluntarily give The Alverno the right to make a thorough investigation of my past employment and activities, including criminal, and I agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information.

Applicant’s Name:______

(Printed)

______

Applicant’s Signature Date

THE ALVERNO

1. What prompted you to apply for a position at our Community?

2. What training, experience, and expertise do you feel you have to offer to our RESIDENTS and TEAM?

3. How do you personally feel about caring for elders?

4. In applying to join our TEAM, do you understand that OUR TEAM does not miss work and cause staff shortages, unless they have promptly and properly notified the Facility with a valid and verifiable reason. Will you support our Absenteeism/Call-In policy? Why or why not? Explain in detail.

5. Why should the selection committee choose you to join our staff?

6. Additional Comments:

ADMAPP Common\Office\Word\Forms\Application – Page 1- 6/03; Rev. 11/04; 2/27/08; 3/25/08; 9/17/09; 5/31/11; 5/2/12