SUMMIT LIVING CENTER

APPLICATION FOR EMPLOYMENT

Summit Living Center is an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability or national origin.  Consistent with the Americans with Disabilities Act, applicants may request accommodations needed to participate in the application process.

 

 

PERSONAL INFORMATION      Date of Application____________________________

                                                                                    Social Security Number_________________________

Name__________________________________________________________________________________

                                    Last                                         First                                        Middle

Current Address_________________________________________________________________________

                                                            Street                                      City                 State               Zip

Permanent Address______________________________________________________________________

                                                            Street                                      City                 State               Zip

Home Phone Number (______)___________________ Cell Phone Number (______)________________

Email Address___________________________ Alternative Phone Number (______)________________

Referred By_____________________________________________________________________________

 

 

EMPLOYMENT INFORMATION 

 

Position applying for_________________________________________ Desired Salary_______________

Are you currently employed? □ yes   □ no     If yes, may we contact your present employer? □ yes   □ no

Have you ever applied with Summit Living Center before?  □ yes   □ no   If yes, when?______________

What date would you be available to start work?______________________________________________

 

 

EDUCATION INFORMATION

                                                                                          Circle last                  Did you              Subjects Studied and

                               Name and location of school         year completed          graduate?              Degrees Received

Grammar School			□ yes   □ no
High School		1     2     3     4	□ yes   □ no
College		1     2     3     4	□ yes   □ no
Business or Vo-Tech		1     2     3     4	□ yes   □ no

 

Special Studies or Certifications____________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EMPLOYMENT REFERENCES

Please complete the following information, starting with your most recent employer

 

Employment Reference #1

Employment Dates   Start Date__________ End Date__________	Name and Address of Employer Name_________________________________ Street_________________________________ City______________State_______Zip_______		Phone Number with area code of Employer   (_____)________________		Name of Supervisor
Position Held		Salary upon leaving		Reason for leaving

 

Employment Reference #2

Employment Dates   Start Date__________ End Date__________	Name and Address of Employer Name_________________________________ Street_________________________________ City_____________State________Zip_______		Phone Number with area code of Employer   (_____)________________		Name of Supervisor
Position Held		Salary upon leaving		Reason for leaving

 

Employment Reference #3

Employment Dates   Start Date__________ End Date__________	Name and Address of Employer Name_________________________________ Street_________________________________ City____________State________Zip________		Phone Number with area code of Employer   (_____)________________		Name of Supervisor
Position Held		Salary upon leaving		Reason for leaving

 

Employment Reference #4

Employment Dates   Start Date__________ End Date__________	Name and Address of Employer Name_________________________________ Street_________________________________ City_____________State_______Zip________		Phone Number with area code of Employer   (_____)________________		Name of Supervisor
Position Held		Salary upon leaving		Reason for leaving

 

Office Use Only:

Reference Check #1     Date: _________________Time:___________ Spoke To: __________________________________________	Reference Check #2     Date: _________________Time:___________ Spoke To: __________________________________________
Reference Check #3     Date: _________________Time:___________ Spoke To: __________________________________________	Reference Check #4     Date: _________________Time:___________ Spoke To: __________________________________________

 

I hereby authorize a representative of Summit Living Center to contact the above listed employment references for verification of the information I have provided.

 

Signature_______________________________________________Date____________________________

 

PERSONAL REFERENCES

Please complete the following information with four persons not related to you and not living in your home that you have known for a minimum of one year.

 

 

PERSONAL REFERENCE #1

Name	Street Address	Phone Number with area code	Number of years acquainted
	City	(_____)_____________
	State                             Zip

 

 

PERSONAL REFERENCE #2

Name	Street Address	Phone Number with area code	Number of years acquainted
	City	(_____)_____________
	State                             Zip

 

 

PERSONAL REFERENCE #3

Name	Street Address	Phone Number with area code	Number of years acquainted
	City	(_____)_____________
	State                             Zip

 

 

PERSONAL REFERENCE #4

Name	Street Address	Phone Number with area code	Number of years acquainted
	City	(_____)_____________
	State                             Zip

 

 

Office Use Only:

Reference Check #1     Date: _________________Time:___________ Spoke To: __________________________________________	Reference Check #2     Date: _________________Time:___________ Spoke To: __________________________________________
Reference Check #3     Date: _________________Time:___________ Spoke To: __________________________________________	Reference Check #4     Date: _________________Time:___________ Spoke To: __________________________________________

 

I hereby authorize a representative of Summit Living Center to contact the above listed personal references for verification of the information I have provided.

 

Signature_______________________________________________Date____________________________

 

If you are to be hired by Summit Living Center, you will be required to attest to your identity and employment eligibility, and to present documents confirming your identity and employment eligibility.  You cannot be hired if you cannot comply with these requirements.

 

 

 

 

 

AUTHORIZATION

 

I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge.  I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by the Summit Living Center.

 

I understand that my employment is conditioned on a background check.  I authorize Summit Living Center to thoroughly investigate all statements contained in my application or resume, and I authorize my former employers and personal references to disclose information regarding my former employment, character and general reputation to Summit Living Center, without giving me prior notice of such disclosure.  In addition, I release Summit Living Center, any former employers and all references listed above from any and all claims, demands or liabilities arising our of or related to such investigation or disclosure.

           

I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract.  I further understand and agree that if I am hired, my employment will be “at will’ and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or Summit Living Center.  No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Summit Living Center unless made in writing.

           

If I am offered employment I agree to submit to a medical examination and drug test before starting work.  If employed, I also agree to submit to a medical examination or drug test at any time deemed appropriate by Summit Living Center and as permitted by law.  I consent to such examinations and tests, and I request that the examining medical professional disclose to Summit Living Center the results of the examination, which results shall remain confidential and segregated from my personnel file.  I understand that my employment or continued employment, to the extent permitted by law, is contingent upon satisfactory medical examinations and drug test, and if I am hired a condition of my employment will be that I abide by Summit Living Center’s drug and alcohol policy.

           

I understand that completing this application does not indicate there is a position open and does not obligate Summit Living Center to hire me.  If hired, I agree to abide by all policies and procedures of Summit Living Center.  Summit Living Center retains the right to revise its policies and procedures, in whole or in part, at any time.

 

 

Signature_________________________________________________Date___________________________