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Employment Application

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

Position

Type of employment desired(Required)
MM slash DD slash YYYY
Have you ever applied or interviewed for a position with Heritage Assisted Living?(Required)
MM slash DD slash YYYY
Have you ever been employed by Heritage Assisted Living?(Required)
MM slash DD slash YYYY

Background

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

Employment History

Hidden
Current Employer(Required)
Name
Address
Employed From
to
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
to
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
to
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
to
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

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.

Electronic Acknowledgement(Required)
Full Name
Initials
Date
This field is for validation purposes and should be left unchanged.

Ed, I wanted to extend my compliments to Britney Grisso Leahey for all she did to make my aunts transition to the Heritage Assisted Living seamless.  After you visited us at her condo 32D Rose Rita Terr Hammonton, we got part time help in and all was well for a while.  However, the help was telling me she was declining and really needed 24/7 care.  Long story short, she fell and broke her back.  She signed herself into your facility realizing she couldn't be alone anymore and we couldn't find 24/7 help.  In addition to her move there, she loves her room, has found friends and is more active than she's been in years.  My husband worked for Hammonton Water Dept when the Heritage came to town.  He had told me on a number of occasions that was a high class facility and now I see why.  Just walking into the foyer, I was struck by how comfortable and safe one feels.  I only hope you are still in business if I need a facility in future.  But with my heart condition, I'll probably die quick.  Especially with my aunt and mother having panic attacks. ha Thanks so much

— April Boyer Maimone

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Heritage Assisted Living
45 US-206, Hammonton, NJ 08037
(609) 561-8977

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