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Working at Kirkhaven
Step 1 of 5 - General Information
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Date
*
Date Format: MM slash DD slash YYYY
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
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Country
Email
*
Phone
*
Alternate Phone
Employment status desired
*
Full-time
Part-time
Per diem
Position Desired
*
How many years of experience do you have in the position for which you are applying?
*
Compensation Desired
*
Date you can begin work
*
Date Format: MM slash DD slash YYYY
Shift preferred
*
Days
Evenings
Night
Can you work weekends/holidays
*
Yes
No
Are you under 18 years of age?
*
Yes
No
If yes, please state your age
Are you legally eligible for employment in the United States?
*
Yes
No
May we contact your current employer?
*
Yes
No
Have you ever been removed from any type of employment?
*
Yes
No
How did you learn of this position?
Have you ever been interviewed by Kirkhaven or Valley Manor?
*
Yes
No
When?
Have you ever beenemployed by Kirkhaven or Valley Manor?
*
Yes
No
For what position
When?
List any volunteer experience:
Are any of your relatives employed by Kirkhaven or Valley Manor?
Yes
No
Name of relative
Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodations?
Yes
No
Highschool
*
Did you graduate?
Yes
No
Other highest grade completed
College and Course of Study
*
Did You Graduate?
Yes
No
Other years completed
Additional Education?
Professional Licenses, Certifications, and Registrations? Provide State, ID number, and Expiration Dates:
Work Experience
*
I have no work experience.
I have work experience. (Please list your last 3 employers, with the most recent first.)
Most Recent Employer
Employer's Address
Supervisor's Name
Phone
Your Position/Title
Hours & shift
Rate of pay
Dates employed?
Reason for leaving
Name of Employer
Employers Address
Supervisor's Name
Phone
Your Position/Title
Hours & shift
Rate of pay
Dates employed?
Reason for leaving
Name of Employer
Employer 's Address
Supervisor's Name
Phone
Your Position/Title
Hours & shift
Rate of pay
Dates employed?
Reason for leaving
Have you served in the US Armed Forces?
No
Yes
If Yes, please list branch of service, dates of service (from month/year - to month/year), and rank attained.
Personal References & Records Check Consent.
Please provide three (3) Personal References:
Records Check Consent.
Have you ever been convicted of a crime?
*
No
Yes
If yes, please describe in full:
If yes, do you possess a certificate of relief from disabilities or a certificate of good conduct from the court?
Yes
No
I understand that a record containing convictions will not necessarily disqualify me from employment with Seniorsfirst, and that consideration will be given to the information provided including: the age of the conviction; age when the crime was committed; the seriousness of the offense;, the relationship of the offense and the job sought;demonstration of rehabilitation; and whether a certificate of relief from civil disabilities has been obtained. I understand that failure to provide Seniorsfirst with full and accurate information regarding any and all names used by me and any and all addresses at which I have resided will disqualify me from consideration for employment and will constitute grounds for discharge from employment.
*
I agree
Pre-Employment Drug Testing
I voluntarily consent to submit to the collection of a urine specimen upon receiving an offer of employment and understand that Seniorsfirst will use this sample for the purpose of conducting tests for illegal/unauthorized drugs. I further understand that evidence of illegal/unauthorized drug use may disqualify me from consideration for employment. I further consent to the exchange of information regarding such tests by and between the testing laboratory, the Medical Review Officer, and Seniorsfirst. I agree to disclose completely all information requested during such testing regarding my physical condition, medication and medical history. I understand that failure to cooperate with the Seniorsfirst drug testing policy will disqualify me from consideration for employment. I hereby release and agree to hold harmless Seniorsfirst, its officerse, directors, employees, and agents from any and all liability whatsoever in connection with any drug testing and the use of the test results. *
*
I Agree
I understand that employment is subject to reference checks, passing of the pre-placement physical, tuberculin test, measles/mumps/rubella test, drug screen, criminal background check, and compliance with the Immigration and Control Act. I understand that this employment application and any other company documents are not contracts of employment and that any individual who is hired may voluntarily leave employment upon proper notice, and may be terminated by Seniorsfirst at any time and for any reason. I understand that any oral or written statements to the contrary are hereby expressly disavowed. I certify that all answers given by me are true, accurate, and complete. I understand that falsification, misrepresentation or omission of fact on the application (or any other accompanying or required documents) will be cause for denial of employment or immediate termination from employment, regardless of how or when discovered.
I hereby authorize all persons, companies, and corporations to release and provide any and all information regarding my employment with them to Seniorsfirst, and do hereby release Seniorsfirst, and all persons, companies and corporation from all liability for issuing this information. *
*
I Agree
Applicant Name (Please Print) This serves as your electronic signature. *
*
PLEASE SCROLL TO THE END OF THE FORM AND SUBMIT YOUR APPLICATION. IF YOU WISH TO ATTACH A COVER LETTER AND/OR RESUME, YOU MAY DO SO HERE:
Interviewed by (Dept) and Date:
Interviewed by (Dept) and Date (check one):
Conduct 2nd Interview/Interested
Send Decline Letter/Hold for future opening/Still Interested
Send Decline Letter/Not Interested
Position, Hours & Shift Interviewed for:
Interviewed by (HR) & Date:
Result of HR Interview:
Position Offered
Accepted
Declined
Decline Letter/Call Delivered
Start Date:
Department:
Position:
Community (check one):
Kirkhaven
Valley Manor
Employment Status (check one):
Exempt
Non-Exempt
Hours (check one):
Full-Time
Part-Time
Enhanced Per Diem
Per Diem
Temporary
Number of Scheduled Hours/Pay Period
Shift:
Supervisor:
Employee Number & Badge Number: