EMPLOYMENT APPLICATION

Transcription

1 EMPLOYMENT APPLICATION Cypress Glen 100 Hickory Street, Greenville, North Carolina Starr Prince, HR Director (252) Cypress Glen is an equal opportunity employer and makes all employment decisions without regard to race, color, national origin, religion, sex, age, disability or status as a disabled veteran or veteran of the Vietnam era. We deeply appreciate your interest in our organization and assure you we are sincerely interested in your qualifications. A clear understanding of your background and work history will aid us in placing you in the position that best meets your qualifications. Please fill out all of the sections below: Applicant Information Applicant Name: Address: City, State and Zip Code: Telephone Number: Address: Date of Application: Employment Position Positions applying for: How did you hear about this position? What days are you available for work? What hours or shifts are you available to work? If needed, are you available to work overtime? On what date can you start working if you are hired? Salary desired: FT PT Personal Information Have you ever worked for Cypress Glen before? If yes, when? Have you ever applied to Cypress Glen before? If yes, when? Do you have any friends, relatives, or acquaintances working for Cypress Glen? If yes, state name and relationship/affiliation: Yes Yes Yes No No No

2 Are you a U.S. citizen or approved to work in the United States? Yes No Education and Training: Please include all dates attended and any degrees or certificates earned. High School Name Location (City, State) Year Graduated Degree Earned College/University Name Location (City, State) Year Graduated Degree Earned Vocational School/Specialized Training Name Location (City, State) Year Graduated Degree Earned CHECK IF APPLICABLE: Certified Nurse Aide Med Tech Medication Aide Nursing Student LicensedPractical Nurse Registered Nurse Graduate Nurse N. C. License/Certificate # Expiration Date Workshops, Institutes, and/or Specialized Training and Dates:

3 Employment Record: List below present and past employment, beginning with your most recent employment. Please complete all information in full, even if submitting a resume. Employer Name: Job Title: Supervisor Name: Employer Address: City, State and Zip Code: Employer Telephone: Dates Employed: Start Date: End Date: Salary: Reason for leaving: Employer Name: Job Title: Supervisor Name: Employer Address: City, State and Zip Code: Employer Telephone: Dates Employed: Reason for leaving: Start Date: End Date: Salary: Employer Name: Job Title: Supervisor Name: Employer Address: City, State and Zip Code: Employer Telephone: Dates Employed: Reason for leaving: Start Date: End Date: Salary: Please provide three personal or professional references below: Name Name Occupation Occupation Address Address Phone Phone Name Occupation Address Phone

4 CYPRESS GLEN VOLUNTARY AFFIRMATIVE ACTION INFORMATION Completion of the information below is voluntary. In an effort to comply with requirements regarding Affirmative Action record keeping, please complete this applicant data survey. Your cooperation is appreciated. The survey is not part of your official application for employment. Your responses will not be used in any hiring decision. Name Date List the title of the position(s) for which you are applying: Gender: Male Female Please identify yourself with one of the following Ethnic Groups: Asian Hispanic or Latino (Includes persons of Mexican, Puerto Rico, Cuban, Central or South American, or other Spanish origin or culture, regardless of race.) Not Hispanic or Latino If you are not Hispanic or Latino, please identify yourself with one of the following Racial Groups: White Black or African American Native Hawaiian or Pacific Islander Other Newspaper Government Agency Employment Agency Job Service Relative Employee Internet Other ADMINISTRATIVE USE Position applied for: Current Opening No Current Opening Other position(s) considered for: Hired: Yes No Hire Date Position Hired for: Position Classification: Office and Clerical Operations (semi-skilled) Craft Workers (skilled) Sales Worker Service Workers Professional Technician Laborers (unskilled) Official and Managers Additional Information: Completed by Date

5 ALL APPLICANTS MUST COMPLETE AND SIGN THE SECTION BELOW COURT RECORD RELEASE FORM All applicants applying for positions (exempt and non-exempt) at Cypress Glen Retirement Community, must agree to an extensive screening process, which inlcudes a court record check. Conviction of a crime does not automatically disqualify an individual from employment at Cypress Glen. In each case, Cypress Glen, examines the nature of the conviction, time elapsed since the conviction, and the type of job you are being considered for. Dependent on all of the circumstances, a decision is made whether to extend a job offer or continue employment of an already hired employee. It is very important all applicants complete this form fully and accurately; therefore, consider your answers carefully.omission OF ANY INFORMATION WILL BE DEEMED FALSIFICATION AND WILL REQUIRE AN APPLICATION BE DEACTIVATED OR AN ALREADY HIRED EMPLOYEE BE TERMINATED. Have you ever been convicted of ANY offense other than a traffic offense? (This includes felonies or misdemeanors. An example of a common misdemeanor is a, "worthless check") Yes No If Yes, please explain the nature of the crime, and give the date and place. If more space is needed, attach another piece of paper to this application. PRINT OR TYPE THE INFORMATION REQUESTED BELOW: Full Name Former Names or Other Names Used Current Address City State Zip Previous Address I HEREBY AUTHORIZE CYPRESS GLEN TO INVESTIGATE ALL STATEMENTS MADE BY ME ON THIS FORM AS WELL AS INFORMATION FURNISHED BY ME ON MY EMPLOYMENT APPLICATION. I AUTHORIZE ANY AND ALL POLICE AND LAW ENFORCEMENT AGENCIES, COURTS OR OTHER AGENCIES TO RELEASE ANY RECORDS OR INFORMATION WHICH MAY HAVE A BEARING UPON CONVICTIONS RELATIVE TO ME. I HEREBY RELEASE ABOVE AGENCIES FROM ANY AND ALL LIABILITY IN CONJUNCTION WITH THE RELEASE OF SAID RECORDS OR INFORMATION. Full Signature Date AGREEMENT (Please read the following statements carefully) I certify that the information on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree falsified information or significant omissions may be considered justification for dismissal, if discovered at a later date. I further agree, upon request, to take a drug screen.

6 I understand if I do not successfully pass the drug screen, an offer of employment will not be extended and I may be terminated if I am already employed. I agree personnel policies, regulations and work schedules are subject to unilateral changes; and I, as an employee, have no legitimate expectations that any particular policy, regulation or work schedule shall remain in force. I understand that nothing contained in this application or in the interview process is intended to create an employment contract between me and Cypress Glen. If I am employed by Cypress Glen, I will be an employee-at-will. This means that both Cypress Glen and I have the right to terminate my employment at any time, for any reason, with or without cause. I also acknowledge that upon receiving an offer of employment, I will be required to successfully complete all pre-employment requirements such as a physical, PPD skin test, drug screen, background check, OIG and references. The facts set forth in my application for employment are true and complete. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal. You are hereby authorized to make any investigation of my personal history and financial and credit record through any investigative or credit agencies or bureaus of your choice. In making this application for employment, I authorize you to make an investigative consumer report whereby information is obtained through personal interviews with my neighbors, friends or others with whom I am acquainted. This inquiry, if made, may include information as to my character, general reputation, personal characteristics and mode of living. I understand that I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of any such investigative report that is made. Full Signature Date

7 Other Notes

8 Cypress Glen is a Continuing Care, Senior Lifestyle Community owned and operated by The United Methodist Retirement Homes, Inc. and managed by Life Care Services LLC. 100 Hickory Street Greenville, North Carolina /06/2014