Riverdale Assisted Living

6880 e. Raines Road

Memphis, Tennessee 38115

901.795.4495 - Office

901.729.6639 – Fax

PERSONAL INFORMATION

Print name as it appears on Social Security Card:
First M Last / Today’s Date
______/______/20___ / Telephone Number
Day ______
Evening ______
Present Address How Long at Address / Apt. No. / City / State / Zip Code
Permanent Address How Long at Address / Apt. No. / City / State / Zip Code
Are you at least 25 years of age or older? * YES * NO / When will you turn 25 years old? / Date of Birth
Are you a legal US citizen? * YES * NO / Social Security Number / Valid Driver License Number and State in which issued:
Race / Ethnicity : (Check one)
0 American Indian / Alaska Native 0 Asian / Pacific Islander
0 Black / African American ( Not of Hispanic origin)
0 Hispanic or Latina Descent 0 White (Not of Hispanic Origin)
0 Unknown

EMERGENCY CONTACT INFORMATION

Spouse / Emergency Information Last First MI / Relation to Applicant / Telephone Number
Day ______
Evening ______
Present Address How Long at Address / Apt. No. / City / State / Zip Code
Permanent Address How Long at Address / Apt. No. / City / State / Zip Code

DESIRED EMPLOYMENT

Position Desired / Date You Can Start / Salary Desired
Are you employed now? * YES * NO / If YES, may we contact your present employer? * YES * NO
Have you ever applied to RAL, LLC before?
* YES * NO / Have you ever worked for RAL, LLC before?
* YES * NO / If YES, please provide the date(s).
How were you referred to RAL, LLC?
* Walk-In * Newspaper Ad * Friend * Other ______

Educational Background

School Level / Name and Location of School / Years Attended / Did you Graduate? / Subjects Studied
Grammar School / * YES * NO
High School / * YES * NO
College / * YES * NO
Trade, Business, or Correspondence School / * YES * NO

MILITARY SERVICE RECORD

Branch of Service / Rank / Start Date / End Date / Discharge Date

EMPLOYMENT HISTORY

(Please list below your past and present employers, beginning with the most recent.) 5 Year Work History. If you need additional space, please request from front desk.

Name of Present Employer / Start Date / End Date
Address / City / State / Zip Code
Job Title / Starting Salary
* WEEKLY * MONTHLY * HOURLY / Ending Salary
* WEEKLY * MONTHLY * HOURLY / May we contact?
* YES * NO
Description of Job Duties
Reason for Leaving / Supervisor’s Name / Contact Number
Name of Present Employer / Start Date / End Date
Address / City / State / Zip Code
Job Title / Starting Salary
* WEEKLY * MONTHLY * HOURLY / Ending Salary
* WEEKLY * MONTHLY * HOURLY / May we contact?
* YES * NO
Description of Job Duties
Reason for Leaving / Supervisor’s Name / Contact Number
Name of Present Employer / Start Date / End Date
Address / City / State / Zip Code
Job Title / Starting Salary
* WEEKLY * MONTHLY * HOURLY / Ending Salary
* WEEKLY * MONTHLY * HOURLY / May we contact?
* YES * NO
Description of Job Duties
Reason for Leaving / Supervisor’s Name / Contact Number
Name of Present Employer / Start Date / End Date
Address / City / State / Zip Code
Job Title / Starting Salary
* WEEKLY * MONTHLY * HOURLY / Ending Salary
* WEEKLY * MONTHLY * HOURLY / May we contact?
* YES * NO
Description of Job Duties
Reason for Leaving / Supervisor’s Name / Contact Number
Name of Present Employer / Start Date / End Date
Address / City / State / Zip Code
Job Title / Starting Salary
* WEEKLY * MONTHLY * HOURLY / Ending Salary
* WEEKLY * MONTHLY * HOURLY / May we contact?
* YES * NO
Description of Job Duties
Reason for Leaving / Supervisor’s Name / Contact Number

REFERENCES

(Please give the names of at least three people you are NOT related to, and have known at least five years.)

Name / Address / Business / Phone Number / Years Known

IMPORTANT BACKGROUND INFORMATION

Do you have a valid driver’s license? * YES * NO Driver’s License Number ______State ______

* FALSIFING INFORMATION ON THIS APPICATION WILL BE GROUNDS FOR TERMINATION: PLEASE SIGN THIS LINE STATING THAT YOU ARE AWARE THAT YOU MUST HAVE A VALID DRIVERS LICENCE IN ORDER TO WORK AT RAL. NAME: ______DATE:______

Have you ever been convicted of a felony? * YES * NO If yes, please explain (include all convictions and dates) IF YES STOP YOU ARE NOT ELIGIBLE ** FALSIFING INFORMATION ON THIS APPICATION IN REGARDS TO WHETHER OR NOT YOU HAVE A FELONY YOU WILL BE TERMINATED IMMEDIATELY AS RAL CAN NOT HIRE A PERSON WITH A FELONY. PLEASE SIGN THIS LINE STATING THAT YOU ARE AWARE THAT YOU CAN NOT HAVE A FELONY AND THAT YOU WILL BE TERMINATED IMMEDIATELY IF YOU AFTER YOUR BACKGROUND COMES BACK AS TO HAVING A FELONY. NAME: ______Date ______

______

Do we have permission to obtain your criminal record? * YES * NO Are you a US citizen? * YES * NO

May we contact your present employer? * YES * NO If no, please explain. ______

______

SPECIALIZED SKILLS, TRAINING AND QUALIFICATIONS

Summarize any special skills, training, and/or qualifications gained from your previous employment, education, or other related experience. ______

______

AUTHORIZATION

I certify that the facts that I have provided on this application are true and complete to the best of my knowledge and understand that, if employed; falsified, misrepresentation, misleading statements, or omission of fact on either the application or any other materials, or during the pre-hire or post-hire process (including during any interviews) will be sufficient reason for (1) denial of employment; or (2) dismissal at any time I am employed. Any offer of employment I may receive from RAL, LLC is contingent upon my completing the Company’s total pre-employment screening process, including RAL’s receipt of references that it considers satisfactory, and my satisfactory completion of any post-job-offer. I authorize and request investigation of all statements contained herein and the references and employers listed above to give Riverdale Assisted Living, LLC any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand that in the event of employment, any false or misleading information given in my application or interview(s) may result in discharge or criminal prosecution. In consideration of my employment, I agree to comply with the policies, rules, regulations and procedures of RAL, LLC. I understand that my employment will be on an at-will basis, which means that RAL or I can terminate my employment with or without cause or notice at any time. I understand that if my assignment should end or change it is my responsibility to call in DAILY to be put on the availability list for a new assignment. My failure to report to work and/or not call in for that day’s absence will indicate that I have resigned and no longer which to be employed by RAL. I also affirm that I have not signed any kind of restrictive document creating any obligation to any former employer that would restrict my acceptance of employment with RAL, LLC.

______/_____/_____

Applicant Signature Date

RAL, LLC EMPLOYMENT REQUIREMENTS

To maintain the trust of our client while working at their homes, RAL, LLC requires good attendance and professional behavior at all time. Unacceptable performance issues, which may constitute grounds for termination, involve the following:

Ø Arriving late or leaving early without authorization

Ø Drug or alcohol use, or intoxication on the job

Ø Not reporting to work when scheduled ( 2 day no report automatic termination).

Ø Disrespectful or abusive language

Ø Failure to follow acceptable dress code

Ø Substandard quality workmanship and/ or productivity levels

Ø Sexual harassment

Ø Horseplay

Ø violence

You must conduct yourself, at all times, in a professional manner, with proper attention to work attitude, quality, productivity and dress code.

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE REQUIREMENTS

______/____/20______/___/20__

Signature Date RAL, LLC Representative Date