Application For Employment

Loudonville Assisted Living Residence
Application For Employment

We consider applicants for all positions with regard to race color, religion, sex, national origin, age, material or veteran status, sexual orientation, citizenship status, disability or any other legally protected status.

Name
First Last
Email
Position Applied For
How did you hear about Loudonville Assisted Living Residence?
Address
Street Address Address Line 2 City State ZIP Code
Phone
If you are under 18 years of age, can you provide required proof of your eligibility to work?
- Yes
- No
If hired, could you present evidence of U. S. citizenship or legal right to live and work in Yes No This United States? (Proof of citizenship or immigration status will be required upon Employment.)
- Yes
- No
Are you currently employed?
- Yes
- No
4. On what date would you be available to work?
5. How many hours per week employment do you seek? Please enter a LEAST and MOST amount.
Part-Time only: What are the times you are available Mon-Sun? Please be as descriptive as possible.
Education
High School Attended
Years Completed
Did you graduate?
Degree Earned
Did you have any special skills?
Did you earn any awards or honors?
College Attended
Years Completed
Did you graduate?
Degree Earned
Did you have any special skills?
Did you earn any awards or honors?
Graduate School Attended
Years Completed
Did you graduate?
Degree Earned
Did you have any special skills?
Did you earn any awards or honors?
Business/Trade School Attended
Years Completed
Did you graduate?
Degree Earned
Did you have any special skills?
Did you earn any awards or honors?
Employment History
Start with your present or most recent job. Include job-related military service assignments and job-related volunteer activities. You may exclude organizations which indicate race, color, religion, sex, national origin, age, marital or veteran status, sexual orientation, citizenship status, disability or any other legally protected status.
Employment
Work Performed
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Company Phone Number
Job Title
Supervisor's Name
Reason for Leaving
Employment
Work Performed
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Company Phone Number
Job Title
Supervisor's Name
Reason for Leaving
Employment
Work Performed
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Company Phone Number
Job Title
Supervisor's Name
Reason for Leaving
EEO Policy
LOUDONVILLE ASSISTED LIVING RESIDENCE maintains a policy of non-discrimination for all employees and applicants in every facet of the company’s operation. In compliance with federal and state laws, Loudonville Assisted Living Residence hires, trains, and promotes all qualified employees without unlawful discrimination on the basis of race, color, religion, sex, national origin, age, material or veteran status, sexual orientation, citizenship status, disability or any other legally protected status.
EMPLOYMENT APPLICATION ACKNOWLEDGEMENT
I certify that all statements made by me on this Employment Application for Loudonville Assisted Living Residence are true and complete to the best of my knowledge. I agree that if any false statements, omissions, misrepresentation has been made by me herein or during the employment process, or if the results of such investigation is not satisfactory, this may be considered sufficient cause for rejection of this application or any offer of employment may be withdrawn. In the event of employment, I understand that misrepresentation or omission of pertinent information in my application or interview(s) may result in discharge.I authorize Loudonville Assisted Living Residence to conduct a thorough investigation of all matters contained in this application, my background references, employment record and other matters related to my suitability for employment. I further authorize my former employers or any third party to disclose to Loudonville Assisted Living Residence all reports and other information related to my suitability for employment, personal or otherwise, without giving me prior notice of such disclosure. In addition I release to Loudonville Assisted Living Residence, former employers and all references listed above, from any and all claims, demands or liabilities arising out of or related to such investigation or disclosure.I hereby authorize Loudonville Assisted Living Residence and any consumer credit reporting agency or bureau employed by Loudonville Assisted Living Residence to make a consumer credit report in connection with this application. These reports my include information concerning my character, general reputation, personal characteristics, and mode of living, which may be obtained from a variety of sources including personal interviews with friends, associates, and neighbors. I understand that I have the right to make a written request in a reasonable period of time to receive additional detailed information about the nature and scope of this investigation. If I am denied employment based wholly or in part on information contained in the report, I understand that Loudonville Assisted Living Residence will provide me with the name and address of the reporting agency making the report.I understand that nothing contained in this application, or conveyed during any interview which may be granted, is intended to create an employment contract. Furthermore, I understand and agree that if hired, my employment is for no definite period and any employment relationship with Loudonville Assisted Living Residence is of an “at will” nature, which means that employment may be terminated at any time, without prior notice, at the option of either myself or Loudonville Assisted Living. I further understand that no representative of Loudonville Assisted Living Residence has the authority to make any assurances to the contrary.I understand that filing out this form does not indicate there is a position open and does not obligate Loudonville Assisted Living Residence to hire me. In the event of my employment by Loudonville Assisted Living Residence, I will comply with all of the rules, policies, procedures and regulations relating to work performance and conduct.I hereby acknowledge that I have read the above statements and understand the same.
Consent
I agree to the Employment Application Acknowledgment
Other Information
If there have been any gaps in your employment during the past 5 years, please provide details in the space provided here:
Please set forth any additional information which you believe would assist Loudonville Assisted Living Residence in making its decision whether to hire you.
References
Please list at least 3 Business references. 1 Personal reference is suggested
Name
First Last
Company
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Number of Years Acquainted
Name
First Last
Company
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Number of Years Acquainted
Name
First Last
Company
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Number of Years Acquainted
Name
First Last
Company
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Number of Years Acquainted
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Loudonville Assisted Living ResidenceApplication For Employment

Education

Employment History

EEO Policy

EMPLOYMENT APPLICATION ACKNOWLEDGEMENT

Other Information

References

Loudonville Assisted Living Residence
Application For Employment