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Employment Application

Use the form below to inquire about employment opportunities with our company.

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.
Full Name*
Permanent Address*
Street Address Address Line 2 City State ZIP Code
Main Phone*
Other Phone
Email*
If you submit a resume, then the remaining fields are optional until the Signature section at the bottom.
Resume Upload (optional)
Accepted file types: doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf, Max. file size: 128 MB.
If you have a resume you'd like to attach, please do so here. This is not required.
Do you have the legal right to live and work in the U.S.?
- Yes
- No
Other name(s) under which you have been previously employed
Names of friends or relatives employed in this organization
Have you ever applied to this organization before?
- Yes
- No
If Yes, give date and position applied for
Have you ever been employed by this organization before?
- Yes
- No
If yes, list dates of employment
Have you ever been convicted of a felony?
- Yes
- No
Convictions are not an automatic disqualification from employment.
If yes, list dates, offenses, and disposition.
It is the policy of this Community to hire only those who are authorized to work in the United States. Any offer of employment, if made, will be conditional upon your immediate production of documentation to prove your eligibility status under the IMMIGRATION REFORM AND CONTROL ACT of 1986. WE ARE AN EQUAL OPPORTUNITY EMPLOYER
Employment Interests
Position(s) Desired or Area of Interest:
- Activities
- Administrative Assistant
- CNA
- Direct Care Worker
- Food Service
- LPN
- Maintenance
- Marketing
- Transportation
- Registered Nurse
- Universal Worker
Date Available
MM slash DD slash YYYY
Type of Employment You Are Seeking:
- Full Time
- Part Time
- Temporary
Can you travel if a job requires it?
How were you referred to our organization?
- Social Media
- Employee
- Paper Advertisement
- Employment Agency
Name of Referral Source:
Education/U.S. Military Service
Where did you attend high school & college? (Click the + button to add a new row)
School Name & Address Major Years Completed Graduation Date
Are you taking any educational course(s) presently?*
- Yes
- No
- I will be soon
If Yes or you will be soon, what and where?
Have you ever served in the U.S. Armed Services?
- Yes
- No
US Military Duties and special training
Rank held at discharge
References
List 3-5 people we may contact who are qualified to evaluate your capabilities. Do not include relatives. (Click the + button to add a new row)
Name Address Occupation Years Known Phone Number
Employment History
Give employment record as completely as possible listing current or most recent employer first. Show unemployed or self-employed periods and indicate dates and comment on each period. Include part time or summer work.
Company (Most Recent)
Street Address Address Line 2 City State ZIP / Postal Code
Phone
Dates Employed
From To
Job Title
Supervisors Name & Title
Type of Business
Base Rate of Pay (Hour/Week/Month)
Start End
Description of duties
Reason for Leaving?
May we contact this employer?
- Yes
- No
Did you have another job before this one?*
- Yes
- No
Company (Second Most Recent)
Street Address Address Line 2 City State ZIP / Postal Code
Phone
Dates Employed
From To
Job Title
Supervisors Name & Title
Type of Business
Base Rate of Pay (Hour/Week/Month)
Start End
Description of duties
Reason for Leaving?
May we contact this employer?
- Yes
- No
Would you like to list another previous job?
- Yes
- No
Company (Third Most Recent)
Street Address Address Line 2 City State ZIP / Postal Code
Phone
Dates Employed
From To
Job Title
Supervisors Name & Title
Type of Business
Base Rate of Pay (Hour/Week/Month)
Start End
Description of duties
Reason for Leaving?
May we contact this employer?
- Yes
- No
Would you like to list a 4th job?
- Yes
- No
Company (Fourth Most Recent)
Street Address Address Line 2 City State ZIP / Postal Code
Phone
Dates Employed
From To
Job Title
Supervisors Name & Title
Type of Business
Base Rate of Pay (Hour/Week/Month)
Start End
Description of duties
Reason for Leaving?
May we contact this employer?
- Yes
- No
Authorization for Release of Employment Information
If you have been unemployed at any time since leaving school, please indicate what you were doing during this time:
I hereby authorize the following companies to release all information to the Community. I also understand that this authorization is valid for 60 days.
1 -
2 -
3 -
4 -
I waive any liability to the Companies listed above, and its employees, from any claims of action for disclosure of information that could adversely affect any new employment opportunity.
Acknowledgement
I understand that nothing contained in this application, or in the granting of an interview, creates an offer of employment. I further understand that if I am offered employment, my employment may be subject to a job related medical screening examination. If I am granted employment, I agree to conform to the rules and regulations of the Community, my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either the Community or me. I understand that no supervisor or representative of the Community, other than the Manager, has the authority to make any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. The policies, procedures and statements contained on this application do not imply, create, or constitute an employment contract. I hereby state that the information on this and all other employment forms is true to the best of my knowledge and belief. I understand that any misstatement of facts will subject me to non-hire and/or termination of employment. Note: Unless renewed, all applications become inactive in 60 days.
Would you like to add a cover letter?
- Yes
- No
Cover Letter (optional)
Max. file size: 128 MB.
Please upload your cover letter here. You may also copy and paste the contents of your cover letter in the space below.
Digital Signature:

Printing your First Name + Middle Initial + Last Name will act as your digital signature.
Date
MM slash DD slash YYYY

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School Name & Address	Major	Years Completed	Graduation Date

Name	Address	Occupation	Years Known	Phone Number

From	To

Start	End

Apply Now

Employment Application

Employment Interests

Education/U.S. Military Service

References

Employment History

Acknowledgement