Signature Employment Application

We are an Equal Opportunity Employer and do not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, gender, marital status, national origin, disability or handicap, or veteran status.
Please read carefully before you sign this application. It must be completed in full, “see resume” is not acceptable.
Full Legal Name: / Today’s Date:
Preferred Name: / Home Phone:
Cellular Phone / Pager: / Work Phone:
Home Address:
City/State/Zip: / Email Address:
Position applying for: / Pay Rate Expected:
What is your preference? Please mark all that apply. / Full Time / Part Time / PRN / Weekends / Shift: 1st 2nd 3rd
On what date would you be available for work? / Preferred work location:
Are you able to relocate? Yes No / Can you travel if required? Yes No
Only US citizens or aliens who have a legal right to work in the US are eligible for Employment. Can you, upon employment provide genuine documentation establishing your identity and eligibility to be legally employed in the United States? Yes No
Have you ever been convicted of, pled guilty or nolo contendere or had adjudication withheld by the court, judge or jury for a crime that is a felony or a first degree misdemeanor? Yes No If yes, please explain:
Answering “yes” does not constitute an automatic bar to employment. Factors such as date of offense, seriousness and nature of the violation(s), rehabilitation and position applied for will be taken into account.
Have you ever been employed by the company or any affiliates? Yes No If yes, please complete the following:
Location: / Title / Position:
Manager’s Name: / Dates Employed:
How were you referred to the company?
Newspaper Advertisement / Employment Agency / Job Fair
Internet Advertisement / Current Employee / Other
Please give the specific name of the referral source:
Do you have any relatives working for the company or any of our facilities? Yes No If yes, please complete the following:
Relative’s Name: / Relationship:
Position Held: / Location:
Consistent attendance and punctuality are essential requirements of every position with this company. Is there anything that could interfere with your regular attendance and punctuality (with or without a reasonable accommodation) if you are offered a position with us? Yes No
Are you physically able, with or without reasonable accommodation, to perform the essential functions of the job(s) for which you are applying? Yes No

Signature Payroll Services, LLC Equal Opportunity Employer

Rev July2012

PREVIOUS EMPLOYMENT HISTORY

Please list previous employment beginning with most recent employer for a minimum of the last five years.
1. / Employer: / Phone:
Street Address: / City/State/Zip:
Job Title: / Manager:
Dates Employed: / From / To / Pay Rate: / Starting / Ending
Reason for leaving:
2. / Employer: / Phone:
Street Address: / City/State/Zip:
Job Title: / Manager:
Dates Employed: / From / To / Pay Rate: / Starting / Ending
Reason for leaving:
3. / Employer: / Phone:
Street Address: / City/State/Zip:
Job Title: / Manager:
Dates Employed: / From / To / Pay Rate: / Starting / Ending
Reason for leaving:
4. / Employer: / Phone:
Street Address: / City/State/Zip:
Job Title: / Manager:
Dates Employed: / From / To / Pay Rate: / Starting / Ending
Reason for leaving:
5. / Employer: / Phone:
Street Address: / City/State/Zip:
Job Title: / Manager:
Dates Employed: / From / To / Pay Rate: / Starting / Ending
Reason for leaving:
Have you ever been discharged or requested to resign from a position? Yes No If yes, please explain:
Please account for any GAPS in EMPLOYMENT other than while attending school:
Dates: / Reason:
Dates: / Reason:
OTHER EXPERIENCE
Please check the areas in which you have had experience or special training:
Long Term Care / Microsoft Word / Microsoft Power Point
Management / Microsoft Excel / Microsoft Outlook
Please list any additional skills that apply:
LICENSES & CERTIFICATIONS
Please provide copies with your employment application.
Type of License or Certification: / State Issued by: / License or Certification #: / Expiration Date:
Have you ever had a certificate or professional license (related to the position you are applying for) revoked or suspended?
Yes No If yes, please explain:
EDUCATION
/
School Name & Location
/
Degree / Diploma / Certification
/ Field of Study
High School:
College:
University:
Graduate School:
Other:
PROFESSIONAL REFERENCES
Please list three professional references that have known you for at least one year.
Name: / Years Known:
Relationship: / Phone Number:
Name: / Years Known:
Relationship: / Phone Number:
Name: / Years Known:
Relationship: / Phone Number:
This company IS AN EQUAL OPPORTUNITY EMPLOYER AND does not discriminate in hiring or any other EMPLOYMENT decision on the basis of race, color, sex national origin, ancestry, veteran status, age, physical or mental disability, or any other category protected by federal, state or local law.
I voluntarily give this company the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take a physical examination, drug and alcohol test, and any future tests as may be required by this company and by the State regulations at such times and places as relates to essential duties I would be required to perform. While this company doe does not perform pre-offer/pre-employment medical tests, I understand that refusal to provide written consent or to submit to post-hire testing, as necessary and as required by the law, will result in my application no longer being considered for employment.
I have knowingly and voluntarily executed the Arbitration Agreement attached hereto.
I certify that the statements contained herein are true to the best of my knowledge and belief. I understand that any false or misleading statement, receipt of unsatisfactory references, drug or alcohol test, criminal background check or prescribed physical examination which reveals that I cannot perform the essential functions of my job with or without reasonable accommodation may prevent or result in termination of employment.
I understand that employment at this company is at will and that this company or I may terminate the employment relationship at any time, with or without cause. I further understand that neither this application nor any other company communication I may receive constitutes an employment contract.
Applicant Signature: / Date:

Our Mission

Our servant-based organization will revolutionize the Long Term Care industry through a culture of stakeholder education and empowerment, combining customized, resident-centered, healthcare services with personalized spirituality and real quality of life initiatives to earn the trust of every resident, family and community we serve.

Our Vision Statement

We want a revolution that will radically change the long-term care landscape forever.

The Revolution

We find ourselves in a time in which there are many hurdles to overcome to simply stay in business, much less to accomplish our goal of unsurpassed resident care. If we choose the path of least resistance, we shall surely meet the same demise as many of our peers and predecessors. Society has systems in place that can work to our disadvantage, and there are those whose purpose is to see us fail. We must face these adversities with resolve, we must overcome obstacles with creativity; we must make our decision with our hearts as well as our minds. Perseverance is required if we are to win the battle of restoring dignity and profitability to the honorable service of caring for others.

How we touch the lives of our Residents

“Always Put Residents First”

During a resident’s stay at this facility, they are afforded many rights regarding their health care and lifestyle. We as healthcare professionals, strive to create an environment that fosters an enhanced quality of life for each of our residents. Each resident deserves to be afforded the right of dignity, respect, choice and self-determination. Each resident should be treated as if they were part of our family.

Our focus is one of making a commitment to our facilities and our residents. We strive to provide the opportunity to experience fulfillment and personal growth throughout their lifespan. Our Quality of Life Initiatives aim to develop programs promoting the continued growth of our residents.

Our residents deserve recognition for what they have accomplished in their lifetime. The "Hall of Fame Café™" provides a perpetual setting in which facilities can celebrate, honor and recognize our residents. This is a celebration to be shared by residents, their families, our staff, and the community.

Signature Payroll Services, LLC Equal Opportunity Employer

Rev July2012