Rockwood South Hill 2903 East 25th Avenue Spokane, WA 99223 (509) 536-6650 Rockwood at Hawthorne 101 East Hawthorne Road Spokane, WA 99218 (509) 466-0411 IMPORTANT complete the application process, you must save this document and submit it, along with your résumé and cover letter, at: http://rockwoodretirement.org/home/quicklinks/careers-at-rockwood/submit-your-resume/ Application for Employment General Information (please print or type and complete all pages in this document) Last Name First Middle Primary Secondary Email Address Desired Position When can you start? What is your availability? Long-term Temporary Summer Full-Time Part-Time If part-time, how many days/hours per week can you work? Shift Preferred (1st, 2nd & 3rd Choice) Preference Day Evening Night Can you rotate shifts? Willing to work weekends? Rotate Approx. Salary Expected Have you applied here before? What or who prompted you to apply here? Have you worked here before? If yes, when? Position Held List any of your relatives who work here: name and relationship Education High School Diploma Junior College Certificate University Degree Post-Graduate Degree School(s) Attended Location Course of Study Degree/Certificate Do you plan to resume your education? If yes, when? 1
Application for Employment Registrations & Certifications Positions for which you are licensed or certified State & License Number Expiration Date Unemployment Period(s) of time when you were not employed (Month/Year) Reasons you were not employed Work Readiness Information How long would you work if hired at Rockwood Retirement Communities? List activities or commitments that may interfere with your attendance or ability to get to work. If requested, can you provide proof of U.S. Citizenship, Visa or Alien Registration? Who do we notify in case of emergency (name, address, phone number)? Have you any physical or mental impairments that would make your full performance difficult? Are you 18 years of age or older? Have you, within the last 7 years, been convicted of an offense involving drugs, narcotics or theft? (Please be ready to explain, if requested.) Skills & Experience List any skills you have for which you believe you should be considered for employment. Job-Related Volunteer Experience Typing Words-Per-Minute 2
Application for Employment Employment History Beginning with your present or most recent employment, list your employers in consecutive order, covering at least the last five years. 3
Application for Employment Read Before Signing Rockwood Retirement Communities does not discriminate on the basis of age, sex, marital status, race, creed, color, national origin, or the presence of any sensory, mental or physical handicap. Rockwood Retirement Communities is in compliance with Section 504 of the Rehabilitation Act. I understand that misstatements or significant omissions of facts in this application may be grounds for discharge from employment. I understand that any offer of employment is contingent upon completion of health requirements and acceptable verification of my application. Regardless of personal preference, I must be prepared to rotate to less desirable shifts should the need of Rockwood Retirement Communities require. I also realize I will be on a 90-day probation period as explained in the Personnel Policies, and that my continued employment depends on my meeting the requirements of Rockwood Retirement Communities. I understand and agree to the above. Signature Date Release of Reference Information I have applied for employment with Rockwood Retirement Communities, and hereby authorize the release of requested information concerning my previous employment record, and know that a complete answer is important to my being hired. I hereby release the parties in question from any or all liability of damage for providing the information requested by Rockwood Retirement Communities. Signature Date Child Abuse Disclaimer I have not been convicted of child abuse or any crime involving physical harm to another person. Further, I am not a perpetrator of substantiated child abuse, as described in chapter 26.44 RCW. Signature Date Employment Authorization (For Rockwood Official Use Only) Job Title Start Date Shift Department Supervisor Full-Time On-Call Part-Time +20 Hours 4 Benefits 20 Hours
Rockwood South Hill 2903 East 25th Avenue Spokane, WA 99223 (509) 536-6650 Rockwood at Hawthorne 101 East Hawthorne Road Spokane, WA 99218 (509) 466-0411 General Background Questionnaire General Information (please print or type) Last Name First Middle Are you currently employed full-time? Have you ever been convicted of a felony? (Please be ready to explain, if requested.) I don t remember Can you pass a screening for illegal drug use? I don t know What should happen to employees who steal in the workplace? thing. It s probably not a big deal. They should receive counseling. They should be permitted to resign without hassle. They should be arrested. They should be reported to the person in charge. It s not my decision. At what dollar amount should employee theft be reported? More than $10.00 More than $50.00 More than $100.00 More than $500 Any amount Driving Information (Answer only if your position would require you to drive Rockwood vehicles.) Do you have a current driver s license?, from this state., from another state., it is suspended temporarily, it is suspended permanently, I have never had a driver s license Will your driver s record show DUIs, accidents or moving violations of which you have been convicted within the last five years? If so, please explain. 5
General Background Questionnaire Work History Are you eligible to be rehired at all previous employers? I don t know When we check your references, will people say that you were a desirable employee? Probably I don t know How many days have you missed in your last year of work? 0 3 4 7 8 10 11 19 20+ How many days were you late to work during your last year of work? 0 3 4 7 8 10 11 19 20+ Which is the most likely reason you would quit a job? Conflict with a supervisor t earning enough money chance for promotion job security Boredom Seeking better opportunity/money Will you work unscheduled overtime?, I can work some, the more overtime, the better, unless I am given sufficient advance notice, I have a part-time job, I desire no overtime I don t know Are you willing to work flexible hours? (e.g. 10 hours one day, 6 hours the next, etc.) It would depend What is the primary reason you are seeking a new position? Better growth opportunity Better income Better hours and working conditions Hassles with current supervisor Better benefit package 6
General Background Questionnaire Why did you leave your previous job? Laid off Temporary/seasonal job Fired/let go Quit If you were dismissed from you last job, which most closely describes the primary reason? (If not applicable, skip to next question.) Late for work Didn t get along with the boss t enough work Unsatisfactory job performance Unexcused absences What is the primary reason you left your previous position? Better growth opportunity Better income Better hours and working conditions Hassles with the supervisor Better benefit package How would you describe your performance at your current or previous job? Excellent Above average Average Below average Poor I don t know What is the most important thing your direct supervisor could have done to help you be more successful in your current or previous position? More training More personal attention More freedom to do things my way More facilities and support people More time off More direction How would your direct supervisor describe your performance at your current or previous job? Excellent Above average Average Below average Poor I don t know IMPORTANT complete the application process, you must save this document and submit it, along with your résumé and cover letter, at: http://rockwoodretirement.org/home/quicklinks/careers-at-rockwood/submit-your-resume/ 7