Employment Application

Personal Information
Employment History
Education History
References
Applicant Attestations
Summary and Submit

Order Number

Application for Employment

We are an Equal Opportunity Employer

Position Applying For: *

RN Marketing Driver PCA Therapy Housekeeping Accounting Clerical Dietary Maintenance Other

Do you know of any restrictions, personal or otherwise, which would restrict the hours you can work? *

No Yes

What date can you begin work? *

Referral Source: *

Advertisement Relative Walk-In Government Agency Employee Other

If Employee or Other, Please Provide Name:

Your Information

First Name *

Last Name *

Address *

State *

How long have you resided at this address? *

City *

Zipcode *

Have you lived in any place other than Pennsylvania in the past three (3) years? *

No Yes

Social Security Number *

Date of Birth *

Email Address *

Emergency Number

Cell Number

Phone Number

Are you protected from lawfully becoming employed due to Visa or Immigration status? *

No Yes

Do you have Working Papers? *

No Yes

Are you over 18? *

Yes No

Employment History

Employer #1

Employer Name

Employer Address

Employer Phone

Start Date

End Date

Position Held

Start Salary

End Salary

Immediate Supervisor

Reason for Leaving

Summary of Duties

May we contact Employer #1 *

Yes No

Additional Employment History?

Yes

Education History

Institution #1

Institution Name

Start Date

End Date

Diploma/Certificate/Degree Received

Diploma Certificate Degree

Diploma/Certificate/Degree Name

Institution Address

Institution Phone

Instructor Reference

Pertinent subjects/skills learned

May we contact this institution?

Yes

Additional Education History?

Yes

References

Reference #1

Reference Name

Years Known

Phone

Relationship

Address

Reference #2

Reference Name

Years Known

Phone

Relationship

Address

Reference #3

Reference Name

Years Known

Phone

Relationship

Address

APPLICANT ATTESTATIONS

All employment offers with The Village at Luther Square dba LIFE Northwestern Pennsylvania are contingent upon the candidate passing a Physical Examination, Drug Screening Test, Criminal Background Examination and Mantoux (2-step TB Test).

In consideration of my employment, I agree to abide by the rules and regulations of The Village at Luther Square dba LIFE Northwestern Pennsylvania, and I understand that these rules and regulations, and any personnel manual, DO NOT constitute a contract of employment. I further understand that no supervisor or representative of the employer has any authority to enter into any agreement for employment for a specified period of time or to make any agreement contrary to the forgoing. *

I affirm that I have read and understand this application. That I have not withheld any information requested and that the statements I have made are true and correct. In the event of employment, I understand that false or misleading information given in my application or interview(s), may result in immediate discharge as willful misconduct. *

I authorize any previous Employers, Educational Institutions, or individuals specified by me in this application to release any and all information regarding my employment or scholastic standing, together with any other information, personal or otherwise, that may or may not be contained on their records, and I hereby release said Employers, Educational Institutions, or Persons from liability for any damage or injury to me arising out of the release of such information. *

I understand that I may be required to undergo physical examination(s) and/or drug testing(s) as a condition of employment. *

I understand that my employment and compensation can be terminated with or without cause and without notice at any time at the option of the employer. *

I understand the employer requires a notice of, 2 weeks for non-clinical positions and 4 weeks for any clinical or salaried position, if the employee decides to resign from their position. *

Applicants Signature *

Date Signed *

APPLICATIONS KEPT ON FILE FOR 6 MONTHS

Applicant must check all attestations before proceeding to final page.