Employment Application

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Name(Required)

First Middle Initial Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone Number(Required)

Primary Phone Number Type(Required)

Secondary Phone Number

Secondary Phone Number Type

I am a U.S. Citizen or National of the U.S., an alien lawfully working for permanent residence, or an alien authorized to work in the U.S.(Required)

Yes

Note: Upon request, prior to commencement of employment, you must provide document that establish your identity and authorization to work in the United States.

Are you under the age of 18?(Required)

Yes

(If your answer is yes, you must supply working papers if hired)

Position

Type of employment desired(Required)

Full-time

Part-time

Temporary

Summer

Position Applied For(Required)

Available Start Date(Required)

Salary Requirement

Vaccination Status

Have you ever applied or interviewed for a position with Heritage Assisted Living?(Required)

Yes

Date

Position

Have you ever been employed by Heritage Assisted Living?(Required)

Yes

Date

Position

Reason For Leaving

Referred By

Background

Have you ever been convicted of, pleaded guilty or “no contest” (nolo contendere) to: Any felony?(Required)

Yes

Pleasae explain

Note: Disclosure of convictions does not automatically disqualify you from employment consideration

If the position requires driving, do you have a valid driver’s license?(Required)

Yes

Employment History

Hidden

Current Employer(Required)

Name

Address

Employed From

Job Title

Starting Salary

Current Salary

Other Compensation

Why are you looking to change jobs?

Supervisors Name

Telephone

May we contact?

If no, explain.

Current Employer(Required)

Name

Address

Employed From

Job Title

Starting Salary

Current Salary

Other Compensation

Current Employer (Cont.)(Required)

Why are you looking to change jobs?

Supervisors Name

Telephone

May we contact? (if no, please explain)

Hidden

Prior Employer(Required)

Use the (+) button to the right to add additional employment

Name

Address

Employed From

Job Title

Starting Salary

Final Salary

Other Compensation

Reason for Leaving

Supervisors Name

Telephone

May we contact?

If no, explain.

Prior Employer(Required)

Use the (+) button to the right to add additional employment

Name

Address

Employed From

Job Title

Starting Salary

Final Salary

Other Compensation

Prior Employer (Cont.)(Required)

Use the (+) button to the right to add additional employment

Reason for Leaving

Supervisors Name

Telephone

May we contact?

If no, explain.

Professional References(Required)

Use the (+) button to the right to add additional references

Name

Relationship

Company

Telephone Number

Education

High School

Use the (+) button to the right to add additional high schools

Name

City, State

Number of Years Completed

Course/Degree

Business or Vocational School

Use the (+) button to the right to add additional schools

Name

City, State

Course/Degree

Number of Years Completed

College

Use the (+) button to the right to add additional schools

Name

City, State

Course/Degree

Number of Years Completed

Graduate or Other School

Use the (+) button to the right to add additional schools

Name

City, State

Course/Degree

Number of Years Completed

Skills Summary

Describe any other experience, skills or qualifications that you feel would help you perform the job for which you are applying.

List any professional, trade, business or civic organizations you belong to that deal with the position for which you are applying. Please explain your participation and list offices held. (Omit any organization which reflects your race, color, religion, age, sex, sexual orientation, marital status or disabilities.)

Applicant Statement

Please Read Carefully

I hereby certify that all of the information provided by me in this application (or any other details or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by Heritage Assisted Living that such employment with Heritage Assisted Living is at-will, for no specified duration and may be terminated by Heritage Assisted Living at any time, with or without cause. I understand that none of the documents, policies, procedures, actions, statements of Heritage Assisted Living or their representatives used during the employment process is deemed a contract of employment real or implied. I understand that no representative of Heritage Assisted Living has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the Administrator of Heritage Assisted Living.

In consideration for employment with Heritage Assisted Living, if employed, I agree to conform to the rules, regulations, policies and procedures of Heritage Assisted Living at all times and understand that such obedience is a condition of employment.

I understand that if offered a position with Heritage Assisted Living, I may be required to submit to a preemployment medical examination, drug screening, background check, and/or credit check as a condition of employment. I understand those unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employment tests and checks will result in withdrawal of any employment offer or termination of employment if already employed.

I hereby authorize any and all schools, former employers, references, courts, and any others who have information about me to provide such information to Heritage Assisted Living and/or any of their representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information.

I understand that this application is considered current for six months. If I wish to be considered for employment after six months from completion of this application, I will need to complete a new application. By electronically signing below I acknowledge that I have read, understand and agree to the above statements.

CAPTCHA

Electronic Acknowledgement(Required)

Full Name

Initials

Date

Phone

This field is for validation purposes and should be left unchanged.