Employment

A. List last three (3) schools attended, starting with most recent. B. List number of years completed. C. Indicate degree or diploma earned, if any. D. Grade Point Average or Class Rank. E. Major field or study. F. Minor field of study (if applicable)

List name and telephone number of three business/work references who are NOT related to you and are NOT previous supervisors. If not applicable, list three school or personal references who are not related to you.

List professional, trade, business or civic associations and any offices held.
EXCLUDE MEMBERSHIPS THAT WOULD REVEAL RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, CITIZENSHIP, AGE, MENTAL OR PHYSICAL DISABILITIES, VETERAN/RESERVE NATIONAL GUARD OR SIMILARLY PROTECTED STATUS

Provide the following information of your past and current employers, assignments or volunteer activities, starting with the most recent (use additional sheets if necessary). Explain any gaps in employment in comments section below.

Please indicate days and hours you are available for work (be specific)

(Example: From 9:00am – to 5:00pm)

I certify that all information I have provided in order to apply for and secure work with my employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete and misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer’s service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representative, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims that may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on the basis prohibited by applicable, local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, ant the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute and agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by there employer’s president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that the federal immigration laws require me to complete an I-9 Form in this regard.

I hereby authorize RIVERSIDE MANOR NURSING AND REHABILITATION CENTER, its employees, agents and representatives, including legal counsel (collectively the “Facility”) to consult with any person, including former employers, (collectively “Persons”) who may have information concerning my qualifications and other considerations relating to my employment at the Facility. I authorize the Facility to obtain information concerning my qualifications and other considerations relating to my employment at the Facility. I authorize the Facility to obtain information relating to my license, education, training, certificaion, experience, current competence and qualifications from any organization.

I further authorize and consent to the release by the Facility to persons of any information and/or documents the Facility may have concerning my qualifications, as long as such release of information is made in good faith.

I hereby release the Facility and any Persons from and and all liability arising out of the release of information, including otherwise privileged or confidential information, concerning my qualifications.

Photocopies of this release will be binding as the original.