Congratulations for choosing to apply for employment at Shenandoah Valley Westminster Canterbury.

At SVWC, we seek to attract, value and retain employees dedicated to providing quality care

in an environment of unsurpassed service excellence. We take this mission seriously and, as a prospective employee, we ask that you consider whether or not you can uphold this commitment. After all, sharing common principles and having a dedicated vision provide the basis for an effective team.

Realizing that quality-centered organizations are built upon havingsuperior employees, we feel this begins with the selection process. Our Human Resource team is available to answer any questions you may have to determine if our organization is a fit for your qualifications, skills, and desires.

Each applicant is asked to carefully consider whether he or she can make a positive difference for our organization, and further our mission to blend caring, quality, and service excellence. If you believe you can, I encourage you to complete the first step of our selection process by filling out this application.

Sincerely,

Cindy Hunter

Director of Human Resources

Shenandoah Valley WestminsterCanterbury

Dear Applicant,

Thank you for choosing to apply for employment at Shenandoah Valley Westminster Canterbury. We would like to share a few important factors that are reviewed as part of our pre-employment screening process.

PLEASE READ CAREFULLY

To protect the dignity and rights of our residents, Shenandoah Valley Westminster-Canterbury is very careful in pre-screening applicants. This includes:

  • Thoroughly verifying past employment and education --- please provide complete information including names and contact numbers
  • A pre-employment drug screen --- please provide the medical clinic with specifics related to prescription drugs you may be taking so that they may properly review them

In addition, we are required by the Virginia Department of Health to:

  • Verify current professional licenses, registrations, or certificates of training.
  • Complete a criminal record check through the state police.

Applications with missing contact information or without signatures will not be considered for employment.

Please feel free to contact the Human Resources Department if you have any questions.

We are happy to be of assistance.

540-535-1514

We appreciate your interest in Westminster Canterbury and taking the time to apply for employment!!

An Equal Opportunity Employer300 Westminster Canterbury Drive

Winchester, Virginia 22603

EMPLOYMENT APPLICATION

Applicants requiring accommodation for the application and/or interview process should contact a representative of the Human Resources Department.

PLEASE PRINT

Date: ______POSITION APPLIED FOR: ______

Name: Social Security #

FirstMiddleLast

Address:

StreetCityStateZip

Home Telephone: ( ) Alternate Phone:(_____)______

Please check any and all that you would consider accepting for employment

Status: Full-Time(over 37 hours) [ ] Part-Time(less than 28 hours) [ ] On-call [ ]

Shift desired: Day [ ] Evening [ ] Night [ ]

If hired, date available for work

Required pay:______

Have you ever applied for a position with or worked for this company before? Yes [ ] No [ ]

If yes, specify dates: From: To:

Are you legally eligible for employment in this country? Yes [ ] No [ ]

(Proof of U.S. citizenship or work eligibility will be required if employed.)

Have you ever been convicted of a crime other than a traffic violation? Yes [ ] No [ ]

If yes, state type and date

(Convictions may be relevant if job related)

Have you ever been convicted of a felony? Yes [ ] No [ ]

If yes, state type and date

(Convictions may be relevant if job related)

Have you ever been excluded from participation in Federal Health Care programs? Yes [ ] No [ ]

Are you at least 16 years of age? Yes [ ] No [ ]

Are you 18 years of age? (required for some positions) Yes [ ] No [ ]

Educational Background

Name / City & State / Years Completed / Did you
Graduate?
High School / Major: / Degree:
College
Other

If you did not complete high school, do you have a high school equivalency diploma (GED)? Yes ____ No ____

Work History

Please list your present and past work experience for the last 10 years, beginning with your current job. Include part-time work, military service, and volunteer experience. Additional experience forms are available if needed.

Please identify and explain all periods of unemployment in excess of two months.

Applications with missing contact phone numbers will NOT be considered.

______

May we contact your present supervisor? Yes [ ] No [ ]

Company or Employer: Full-time [ ] Part-time [ ]

Your Position:

Address:

Dates Employed: to

Duties:

Phone: ( )

Immediate Supervisor:

Title: Starting Salary:

Last Salary:

Reason for leaving:

Your name when employed if different from present:

Company or Employer: Full-time [ ] Part-time [ ]

Your Position:

Address:

Dates Employed: to

Duties:

Phone: ( )

Immediate Supervisor:

Title:Starting Salary:

Last Salary:

Reason for leaving:

Your name when employed if different from present:

Company or Employer: Full-time [ ] Part-time [ ]

Your Position:

Address:

Dates Employed: to

Duties:

Phone: ( )

Immediate Supervisor:

Title:Starting Salary:

Last Salary:

Reason for leaving:

Your name when employed if different from present:

Please list Licenses, Certificates, Professional Memberships, Honors, etc.

(License #, State, and Expiration Date Required for Nursing Personnel)

______

Use this space for any skills or additional information that you feel will help us to evaluate your application.

______

Please list any family members/relatives currently employed by SVWC:

______

PERSONAL REFERENCES (Do not include relatives and include at least one professional reference)

Name______

Address______

City, State, Zip______

Day Phone #______

Relationship______

Years Known______

Name______

Address______

City, State, Zip______

Day Phone #______

Relationship______

Years Known______

Name______

Address______

City, State, Zip______

Day Phone #______

Relationship______

Years Known______

JOB CANDIDATES CERTIFICATION AND AUTHORIZATION FOR RELEASE OF INFORMATION

(Please read carefully)

I have applied for employment with Shenandoah Valley Westminster Canterbury and I certify that the information given by me in this application is true and complete in all respects. I agree that any omission or misrepresentation by me on this application may result in automatic rejection of this application, and, if I am employed, subject me to automatic termination. I am aware that my background is to be investigated and with this authorization, or copy hereof, I hereby authorize any person and entity to furnish Shenandoah Valley Westminster Canterbury any information concerning me, my work performance, driving record, school record, and criminal record.

I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

This application is current for 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary.

DateSignature of Applicant

AN EQUAL OPPORTUNITY EMPLOYER

Male/Female/Veteran/Disabled

HR/Forms/Application.doc

Revise 3/20/13 ARK

PDF

AFFIRMATIVE ACTION VOLUNTARY INFORMATION

Shenandoah Valley Westminster Canterbury has an affirmative action program to ensure equal employment opportunity in its hiring practices. We are asking you to voluntarily help us monitor the effectiveness of our program by completing the affirmative action data below. The completion of this form is voluntary and refusal to complete it will not subject applicant to any adverse treatment. This form will be filed separately from your application and the provided information will not be used to discriminate against you in any way. Thank you.

Position(s) applied for:

Date:

APPLICANT INFORMATION

Name (optional):

FirstMiddleLast

Sex (Check only one):

( ) Male

( )Female

Ethnic Original (Check only one):

()White

()Black (not of Hispanic origin)

()Hispanic

()American Indian/Alaskan Native

()Asian/Pacific Islander

()Other

Veteran Status:

()Vietnam Era

()Korean War

()Other veteran status

Referral Source: (Please be specific in an effort to help us with advertising)

()Walk-in

()Friend/Relative

()Telephoned our office

()Westminster Canterbury Employee: (If so whom?)

()Virginia Employment Commission

()Newspaper: (name)

()Radio: (name)

()School: (name)

( ) Other______

Equal Opportunity Employer

People are the key to achieving our business objectives and people constitute our most important asset. It is the policy of Shenandoah Valley Westminster Canterbury to provide equal employment and advancement opportunities to qualified persons in a manner which does not discriminate against any person because of race, color, religion, sex, national origin, marital status, or disability.