Mountain Manor of Paintsville Employment Application

Mountain Manor of Paintsville Employment Application

This application is not an employment contract. It is the policy of the company to provide equal employment opportunity to all qualified persons without regard to race, creed, color, sex, age, sexual orientation, ancestry, national origin, religion, mental or physical disability, marital status, family status, pregnancy, genetic information or veteran status or any other characteristics protected by applicable law.

GENERAL INFORMATION:

Name: ______Application Date: ______

Address: ______

StreetCityStateZip

Cell Phone: ______Home Phone: ______

Email Address: ______

1. Are you legally authorized to work in the U.S. on an unrestricted basis? Yes No

(if hired, you will be required to submit proof of your identity and legal authorization as a condition of employment)

1. Are you over 18 years of age? Yes No
2. Are you related to anyone currently employed by the company? Yes No
3. Have you previously been employed by this company? Yes No
4. Are you on layoff and subject to recall? Yes No
5. Are you currently bound by a non-compete and/or employment agreement of any kind? Yes No

If you answered “Yes” for question 6, please briefly explain: ______

1. Have you ever been discharged or asked to resign from a job? Yes No

If you answered “Yes” for question 7, please briefly explain: ______

1. Have you ever been convicted of a misdemeanor or felony? Yes No

(Conviction will not necessarily disqualify an applicant for employment)

If you answered “Yes” for question 8, please briefly explain: ______

1. Have you ever been disciplined or convicted for abusing, neglecting or mistreating an individual in a health care

setting?  Yes No If “Yes” for question 9 give details:______

1. Have you ever been disciplined for unprofessional or unethical conduct?  Yes No If “Yes” for question 10, provide details:

______

EMPLOYMENT DESIRED:

Position: ______Date you can start: ______Wage/Salary Desired: $______

Ever applied with company?  Yes NoIf answered “Yes”, when? ______

1. How did you learn of this opening? ______
2. Have you been told the essential functions of the job or have you been shown a copy of the job description listing the essential functions of the job?  Yes  No
3. If you answered “Yes” for #12, can you perform the essential functions, with or without reasonable accommodation?  Yes  No
4. Are you willing and able to work overtime as required?  Yes No
5. Are there any hours, shifts, or days you cannot or will not work? ______
6. Employment preferred: Full-time Part-time

EDUCATION:

Education / Name and Location of School / Graduated/Completed / Major / Diploma/Degree
High School /  Yes No
College/Univ. /  Yes No
College/Univ. /  Yes No
Other Training/Education

Licensed/Certified Applicants Only:License Number: ______State Issued: ______

Expiration Date: ______Status: ______

1. Has your license/certification to practice in any state ever been voluntarily or involuntarily relinquished, denied, limited, suspended, or revoked?  Yes  No
2. Have you ever been asked to surrender your license or certification/registration. Yes No

If you answered “Yes” for question 17 or 18 please briefly explain: ______

WORK HISTORY: May we contact your present employer?  Yes No Do NOT attach a resume in place of completing.

1 / Current Employer: / Address / Telephone
Hire Date / Starting Pay: $ / Per (Select One) / Starting Position:
Date Left / Pay on Leaving $ / Per (Select One) / Position on Leaving
Name and Title of Supervisor
Description of Duties / Reason for Leaving
2 / Previous Employer: / Address / Telephone
Hire Date / Starting Pay: $ / Per (Select One) / Starting Position:
Date Left / Pay on Leaving $ / Per (Select One) / Position on Leaving
Name and Title of Supervisor
Description of Duties / Reason for Leaving
3 / Previous Employer: / Address / Telephone
Hire Date / Starting Pay: $ / Per (Select One) / Starting Position:
Date Left / Pay on Leaving $ / Per (Select One) / Position on Leaving
Name and Title of Supervisor
Description of Duties / Reason for Leaving

1. In addition to work history, what experiences, skills, or qualifications would fit you for work with the company? ______
2. Please account for any periods of unemployment: ______

PROFESSIONAL REFERENCES: Please list three (3) professional references, who are not relatives, which we may contact. References should have personal knowledge of your work abilities and habits.

Name / Phone Number / Relationship

APPLICANT’S CERTIFICATION AND AGREEMENT:

1. I understand that nothing in this application, or in the granting of an interview, is intended to create an employment contract between the company and myself for either employment or providing of any benefits. I fully understand that any offer of employment will only be made in writing.
2. I certify that the facts set forth in this Employment Application are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of facts on this application (or any required documents) will be cause for denial of employment or immediate termination, regardless of when or how discovered.
3. I understand the company may require an investigative report from a consumer reporting agency with may include information regarding my criminal background, work history, education, professional licensing/certification. I authorize the company to make an investigation of any of the facts set forth in this application and release the company from any liability that might result from making the investigation.
4. If I am offered and accept a position, I agree to conform to all existing and future company rules and regulations and I understand the company reserves the right to change wages, hours, and working conditions as deemed necessary. I understand that if I accept a position at the company, I will be an employee-at-will, which means that either I or the company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis.
5. I understand that any employment offer is contingent upon my providing valid proof of identify and eligibility to work upon my first (1st) day of hire, to comply with the Immigration Reform and Control Act of 1986.
6. I understand that no supervisor, manager, or executive of the company, other than the Owners in signed writing, has the authority to alter the foregoing.
7. I have read and reviewed the information provided in this application and the above statements. By signing this application for employment, I certify that I have had the opportunity to ask questions, understand all parts of the application, and have answered all questions completely and fully.

______

Applicant’s Name – PrintedDate

______Revised: 6/14/2017

Applicant’s Name - Signature