Edgewater Place | Application
15859
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Personal Information:

Name:

Address

City

State

Zip Code

Phone

Alternate Phone

Social Security Number

Email Address


Position Sought:

Position Desired

Wage/Salary Expected

On what date you will be available for work?

Are you available to work:Part-TimeFull-Time

Shift Availability:1st Shift2nd Shift3rd Shift

Are you available to work weekends:YesNo

How did you learn of this position?

NewspaperReputation of facilityEmployeeWebsiteOther


General Information:

Federal law requires applicants to present certain documentation to verify their identity and United States status or their legal authorization to work in the United States.

Are you legally eligible for employment in the United States? YesNo

Are you 18 years of age or older?YesNo

Do you have a valid driving license? (If job related)YesNo

Have you been a member of armed forces of the United States?YesNo

Have you been convicted of, pled guilty to, or received a suspended sentence for a felony or misdemeanor other than a minor traffic violation? YesNo

If yes, please explain:

Have you ever been excluded from participating in the medicare/medicaid program? YesNo

If yes, please explain:


Education:


High School

Name of School

Location(City+State)
Last Completed Year
Major Course Of Study
Graduated/Degrees


College

Name of School

Location(City+State)
Last Completed Year
Major Course Of Study
Graduated/Degrees


Graduate

Name of School

Location(City+State)
Last Completed Year
Major Course Of Study
Graduated/Degrees


Business, Trade or Apprentice

Name of School

Location(City+State)
Last Completed Year
Major Course Of Study
Graduated/Degrees


Professional certificates:

Type of license

License#

Issuing State

Expiration Date

Please list any special Job-related skills, certifications, and qualifications acquired from education, employment, volunteer work or military service which you feel may be helpful in considering your application.


References:

Please list three references who are not related to you and who are not previous employers.

Name

Street Address

City,State,Zip

Phone Number

Relationship


Employment History:

Starting with your present or most recent job, list your employment experience.You may include job related military service assignments and volunteer activities that reflect your qualification for employment.


Company Name

Mailing Address

Phone Number


Job Title

Name of supervisor

Employment Dates

From:

To:

Salary/Hourly Rate

Start:

End:

May we contact this employer?YesNo

If no, state reason.

Reason for leaving?


Company Name

Mailing Address

Phone Number


Job Title

Name of supervisor

Employment Dates

From:

To:

Salary/Hourly Rate

Start:

End:

May we contact this employer?YesNo

If no, state reason.

Reason for leaving?


Company Name

Mailing Address

Phone Number


Job Title

Name of supervisor

Employment Dates

From:

To:

Salary/Hourly Rate

Start:

End:

May we contact this employer?YesNo

If no, state reason.

Reason for leaving?


Company Name

Mailing Address

Phone Number

Job Title

Name of supervisor

Employment Dates

From:

To:

Salary/Hourly Rate

Start:

End:

May we contact this employer?YesNo

If no, state reason.

Reason for leaving?


Applicant's Statement:

  • I authorize investigation of all statements contained in the application for employment as may be necessary in arriving at an employment decision. I understand that an investigation may be made and information may be obtained through interviews with the personal references and past employers listed. I further understand any conditional offer of employment will involve obtaining a criminal background report, pre-employment drug screen, and/or driver license verification. I hereby authorize the organization, if they wish, to make such inquiries.
  • I hereby release all parties, personal references, and previous employers from any and all liability for any injury or damage that may result from their furnishing information to our organization concerning me or any action that we take on the basis of such information.
  • I understand that a physical examination may be required after an employment offer is made, with a report submitted, to be eligible for employment at Edgewater Place.
  • I understand that this application is not a contract of employment and that any resulting employment relationship is for no fixed period of time and is terminable at any time and for any reason by this organization, or by me. I further understand that statements which may be contained in policies, practices, handbooks or other material do not create any guarantee of employment and that this organization has the right to modify, amend, or terminate policies, practices, benefits plans, or other programs within the limits and requirements imposed by law. I understand that no representative of this organization, other than a corporate officer, has the authority to enter into any agreement for any specific period of time or to make any agreement contrary to the foregoing and that any such agreement must be in writing, signed by an authorized officer, and be specifically for employment, to be binding on the organization.
  • I certify that this application was completed by me and that all entries on it and all information contained in (this application, resume, and any supplement thereof) is CORRECT and COMPLETE to best of my knowledge. In the event of employment, I understand that false, misleading, or omitted information given in my application (or during interviews) may result in termination.


Date

Signature of Applicant


This information will be considered active for 6 months and retained for 12 months.


Edgewater Place Applicant Release Form

As an applicant for employment, I authorize Edgewater Place to confirm by personal inquiry information related to past employment, education or other applicable history, and releases from all liability or responsibility all persons, companies, or organizations responding to such inquiries. I understand that I will be subject to a background check.


Applicant Name

Date


Applicant signature