Name *

Address *

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Phone Number *

E-mail *

Location Applying For Stanley Mondovi Durand Dorchester

Willing to work Full-Time Part-Time

Position Applying For:

Number of Hours available per week

Shift Preference 1st 2nd 3rd

Do you have a valid driver's license? Yes No

Driver's License Number

Have you been convicted of any crime in the last 3 years? Yes No

(Conviction will not necessarily disbar an applicant from employment)

If yes, please explain

Have you ever worked at The Homeplace before? Yes No

If yes, when did you work here?

Dates Worked Start Date End Date

Dates Worked #2 Start Date End Date

Employer #1

May we contact most recent employer? Yes No

Employer Phone

Address

Dates Worked Start Date End Date

Position

Supervisor Salary

Reason for Leaving

Employer #2

Employer Phone

Address

Dates Worked Start Date End Date

Position

Supervisor Salary

Reason for Leaving

Employer #3

Employer Phone

Address

Dates Worked Start Date End Date

Position

Supervisor Salary

Reason for Leaving

Elementary School

School Name

Location

Years Completed

High School

School Name

Location

Years Completed

College / University

School Name

Location

Years Completed

Gradudate / Professional

School Name

Location

Years Completed

Describe any specialized training

*Give name, address, and telephone number of three references who are not related to you.

Reference #1

Name

Phone Number

Address

Reference #2

Name

Phone Number

Address

Reference #3

Name

Phone Number

Address

1. I certify that the information contained in this application is correct to the best of my knowledge and understand that deliberate falsification of this information is grounds for termination.

2. I authorize the references listed to give you any and all information concerning my previous employment and pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

3. I acknowledge that The Homeplace Assisted Living retains the right to terminate my employment at will.

I have read and understood the employment agreement