Personal Data
Title
DR
MISS
MR
MRS
MS
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Last Name *
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WESTERN SAHARA
YEMEN
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ZIMBABWE
Social Security #
Work Phone Number *
Home Phone Number *
Cell Phone Number *
Best time to contact you
Position Sought
Salary Requested
Will you accept full-time work?
Will you accept part-time work?
Will you work all shifts including overtime?
Date Available
How were you referred to us?
Are you of legal age to work?
Are you a U.S. citizen or have a legal right to be employed in the U.S.? (If yes,
proof is required)
Can you perform the essential functions of the job(s) for which you are applying?
Do you have a position with another employer that would continue if employed by
us?
If travel is required, do you have any restrictions?
Can you work overtime without prior notice?
Do you have any experience from military service that would be relevant to the
job(s) for which you are applying?
If Yes, please explain
Have you ever been convicted of a felony or released from prison in the past five
years?
If Yes, please explain (Note: A yes answer does not automatically disqualify you
from employment, since the nature of the offense, date and type of job for which
you are applying will be considered)
EMPLOYMENT HISTORY (Please list your present or most recent employer first)
May we contact your most recent employer?
Employer
Phone #
Address
Employed (from-to)
Position Title
Wage/Salary
Supervisor's Name
Reason for Leaving
Nature of work performed and responsibilities:
Employer
Phone #:
Address
Employed (from-to)
Position Title
Wage/Salary
Supervisor's Name
Reason for Leaving
Nature of work performed and responsibilities
Employer
Phone #
Address
Employed (from-to)
Position Title
Wage/Salary
Supervisor's Name
Reason for Leaving
Nature of work performed and responsibilities
Education
High School Name
High School City, State, Zip
High School Major/Course of Study
High School Highest Level Completed
High School Degree
College Name
College City, State, Zip
College Major/Course of Study
College Highest Level Completed
College Degree
Graduate School Name
Graduate School City, State, Zip
Graduate School Major/Course of Study
Graduate School Highest Level Completed
Graduate School Degree
Business/Trade Name
Business/Trade City, State, Zip
Business/Trade Major/Course Study
Business/Trade Highest Level Completed
Business/Trade Degree
Other (describe) Name
Other (describe) City, State, Zip
Other (describe) Major/Course of Study
Other (describe) Highest Level Completed
Other (describe) Degree
In exchange for the consideration of my job application with Grace Manor at North Park (hereinafter called "the Company"), I agree that:
Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or confer any right to remain an employee of the Company, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned; and that relationship cannot be altered except by a written instrument signed by the President of the Company. Both the undersigned and the Company may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.
I authorize the investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contact. I agree that the Company or any of its subsidiaries shall not be liable in any respect if my employment is terminated because of falsity of statements, answers, or omissions made by me on this application.
I understand that in connection with the routine processing of my employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics and mode of living. Upon written request from me, the Company will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act. In addition, if I am required to operate a motor vehicle in the course of my job, the Company is authorized to request a report of my driving record (MVR) and I understand any offer of employment is contingent on an acceptable report.
I further understand that my first ninety (90) days of employment with the Company shall be considered an orientation period, and further that at any time during the orientation period or thereafter, my employment relations with the Company is terminable at will for any reason by either party. In addition, I understand that no promise, representation or agreement to the foregoing is binding on the Company unless made in writing and signed by me and the President of the Company.