doctor in coat and nurse in scrubs with clipboard

Employment Application

APPLICATION FOR EMPLOYMENT

St. Anne's Retirement Community is an Equal Opportunity Employer. We consider applicants for all positions on the basis of qualifications and withoutregardtorace, color, creed, national origin, ancestry, age, sex, religion, basis of genetic information, handicap, disability, marital status,sexualorientation,veteran status or any other legally protected status.

PERSONAL INFORMATION

First Name*:
Last Name*:
Street*:
City*:
State*:
Zip Code*:
Phone Number*:
Email Address*:
Have you lived in the state of Pennsylvania for the past two years?*:
Have you previously been employed at St. Anne's?:
If yes when and why did you leave?:
Are you 18 years of age or older?*:
Are you legally eligible for employment in the United States? (If offered employment, you will be required to provide documentation to verify eligibility.)*:
How did you learn about us?*:
Referred by:
Have you ever been convicted of a felony or misdemeanor?*:
If YES, explain:
(Note: Employment will be considered to the extent that convictions are not on the prohibited list for hire in Long Term Care Facilities.)
Have you ever been involved in or reported for abusing or neglecting a client?*:
Do you have a history of or conviction for violent crimes?*:
Have you ever been terminated or dismissed from employment due to abuse of clients, residents or fellow employees?*:
Criminal background checks are required and completed for all applicants and employees.

EMPLOYMENT DESIRED

Position Applying for*:
Salary Desired*:
Alternate Position Applying for:
Salary Desired for Alternate Position:
Select An Employment Type*:
Shift Desired*:
Shift Desired (second choice):
Date you can start*:

EDUCATION

Number of Years of HIGH SCHOOL Completed*:
High School(s)*:
City/State*:
Do you have a Diploma?*:
G.E.D.*:
Number of college years completed*:
College(s):
City/State:
Major:
Degree(s) Earned:
Vocational/Technical School Certificates:
Please describe additional skills, training or ability you would like to have us consider in evaluating your qualification:

U.S. MILITARY SERVICE

Date Of Service (From - To):
Branch:
Rank and Principal Duties:
Type Of Discharge:

EMPLOYMENT HISTORY

May we contact your present employer?*:
If any employment was under a different name (i.e. maiden name), indicate name:
List names of employers, in consecutive order, below including Military Service.
Please list your PRESENT or MOST RECENT employer FIRST.
Employer #1 - Name*:
Employer #1 - Position*:
Employer #1 - Address*:
Employer #1 - Telephone*:
Employer #1 - Dates of Employment
From (mo/yr) -
To (mo/yr)*:
Employer #1 - Pay (Start $/ Final $):
Employer #1 - Reason for Leaving*:
Employer #2 - Name:
Employer #2 - Position:
Employer #2 - Address:
Employer #2 - Phone:
Employer #2 - Dates of Employment
From (mo/yr) -
To (mo/yr):
Employer #2 - Pay (Start $/ Final $):
Employer #2 - Reason for Leaving:
Employer #3 - Name:
Employer #3 - Position:
Employer #3 - Address:
Employer #3 - Phone:
Employer #3 - Dates of Employment
From (mo/yr) -
To (mo/yr):
Employer #3 - Pay (Start $/ Final $):
Employer #3 - Reason for Leaving:

PERSONAL REFERENCES

Please provide the names of three individuals, not related to you, whom you have known for at least two years.
Reference #1:
Reference #1 - Name*:
Reference #1 - Address*:
Reference #1 - Phone*:
Reference #1 - Occupation*:
Reference #1 - Years Acquainted*:
Reference #2:
Reference #2 - Name*:
Reference #2 - Address*:
Reference #2 - Phone*:
Reference #2 - Occupation*:
Reference #2 - Years Acquainted*:
Reference #3
Reference #3 - Name*:
Reference #3 - Address*:
Reference #3 - Phone*:
Reference #3 - Occupation*:
Reference #3 - Years Acquainted*:

AGREEMENT

I have applied/accepted employment at St. Anne’s Retirement Community. In doing so, I understand that St. Anne’s Retirement Community has a specialobligation to clients, residents and staff in respect to their personal property and safety. I hereby give St. Anne’s Retirement Community the righttomake a thorough investigation into my previous employment, education, references, character and I release from all liability all persons supplyingsuchinformation. The investigation is not limited to the above and criminal checks both State and Federal can be required. I authorize all public officialsorpersons involved in reference for employment to furnish information necessary for employment at St. Anne's Retirement Community. Records obtained will beconfidential.
I release, indemnify, and hold harmless St. Anne's Retirement Community from and against any and all liability that might result from making such aninvestigation. I also understand that any false statement, or misrepresentation made by me in this application shall constitute sufficient cause for discharge.
I understand that nothing contained in this employment application or granting an interview is intended to create an employment contract between St.Anne'sRetirement Community and myself for either employment or for the granting of benefits.
No promise regarding employment has been made to me, and I understand that no such promise or guarantee is binding upon St. Anne’s Retirement Communityunless made in writing. Employment offers are contingent upon the successful completion of all of St. Anne’s pre-employment requirements. If anemployment relationship is established, I understand and agree that it is not for a definite period of time and that I have the right to terminate myemployment at any time and that St. Anne's Retirement Community retains a similar right. I understand that, if accepted for employment, it is necessary toabide by the rules and policies of St. Anne’s Retirement Community.
I affirm that I have a genuine intent and no other purpose in applying for a job with St. Anne's Retirement Community
By checking this box, I acknowledge I have read the agreement above::