Lavender Springs Job Application

1
Legal Name* This field is required.Please enter your full name
First Name
Middle Name
Last Name
2
Please list other names you have gone by(maiden name, married name, nickname, etc)
Separate names using a comma (,)
3
Address* This field is required.Please provide your current address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Cell Phone Number* This field is required.
Area Code
Phone Number
5
Email Address* This field is required.
example@example.com
6
Social Security Number* This field is required.
7
Have you ever worked for Lavender Springs before?* This field is required.
YESNO
8
How did you hear about Lavender Springs?* This field is required.
Newspaper
Radio
Friend/Relative
Website
Other
9
Briefly state why you would like to work for Lavender Springs.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
10
Position(s) you are applying for* This field is required.Select all that apply
Full-Time
Part-Time
PRN
11
Number of hours desired per week* This field is required.Since you selected with Part-Time or PRN, please specify your number of desired number of hours per week.
12
Are you available on weekends?* This field is required.
YESNO
13
Are you available on holidays?* This field is required.
YESNO
14
Days of the week you are available to work* This field is required.Check all that apply
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
15
What shifts are you available to work?* This field is required.Select all that apply
5:45AM - 2:00PM
1:45PM - 10:15PM
10:00PM - 6:00AM
7:15AM - 6:15PM (Kitchen Only)
16
What is the earliest date you can begin?* This field is required.
Date
Year
Month
Day
17
What is your desired hourly wage?* This field is required.
18
Education Level* This field is required.Select all that apply
High School
College/University
Trade School
Licensure/Certification
Other
19
High School* This field is required.
Name of School
Dates Attended
Degree Received
20
College / University* This field is required.
Name of School
Dates Attended
Degree Received
21
Trade School* This field is required.
Name of School
Dates Attended
Certification Received
22
Licensure / Certification* This field is required.
Name of School
Dates Attended
License or Certification Received
23
Do you speak any foreign languages?If so, please list which languages you speak
24
Computer SkillsPlease list any computer skills you have
25
Most Recent Employer* This field is required.Please tell us about your most recent employer
Name of Company
Name of Supervisor
Telephone
Address, City, and State.
Position
Starting and Ending Wage
Dates of Employment
Reason for Leaving
26
Employer (2)Please tell us about your most recent employer
Name of Company
Name of Supervisor
Telephone
Address, City, and State.
Position
Starting and Ending Wage
Dates of Employment
Reason for Leaving
27
Employer (3)Please tell us about your most recent employer
Name of Company
Name of Supervisor
Telephone
Address, City, and State.
Position
Starting and Ending Wage
Dates of Employment
Reason for Leaving
28
References* This field is required.Please list any personal or professional references
Name
Phone Number
Name
Phone Number
Name
Phone Number
Name
Phone Number
29
I hereby certify that I have not knowingly withheld any information that might adversely affect my changes for employment and that answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement on this application or on any documents used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.* This field is required.
30
I hereby authorize Lavender Springs to thoroughly investigate my references, work records, education, and other matters to my suitability for employment and authorize my current and former employers to disclose the company any and all letters, reports, and other information pertaining to my employment with them, without giving me prior notice of such disclosure. In addition, I hereby release Lavender Springs, my current and former employers, and all other persons, corporations, partnerships, and associations from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure.* This field is required.
31
I understand that if offered employment, the offer is contingent on passing a pre-employment alcohol and drug screen. By signing his application, I voluntarily agree to submit to a pre-employment alcohol and drug screen upon receipt of a verbal offer of employment. I understand that failure to pass the alcohol and drug screen will result in withdrawal of the employment offer.* This field is required.
32
If hired, I also agree to submit to random alcohol or drug testing as a condition of employment. I agree that Lavender Springs may conduct alcohol and drug screening at its sole discretion with or without notice, with or without cause or reason. I also understand that refusal to submit to a random alcohol and drug screen will be considered a voluntary resignation of employment.* This field is required.
33
I understand that nothing contained in the application or conveyed to me during an interview which may be granted is intended to create an employment contract, implied or explicit, between me and Lavender Springs. In addition, I understand and agree that if I am employed, my employment relationship with Lavender Springs is strictly voluntary and at our mutual will. I understand that if employed, my employment is for no definite period and may be terminated at any time, with or without prior notice, with or without cause or reason, at the option of either myself or Lavender Springs, and that no promises or representations contrary to the forgoing are binding on Lavender Springs in writing and signed by the Executive Director and myself.* This field is required.
34
I understand and agree that any future changes in my title, duties, compensation, working conditions, and/or Lavender Springs benefits, policies, and procedures will not alter our at-will agreement.* This field is required.
35
I understand that if offered employment, I will, as a condition of employment, be required to submit proof of my identity and legal right to work in the United States on my first day of employment.* This field is required.
36
I hereby authorize Lavender Springs Residential Assisted Living to thoroughly investigate my record with the Texas Department of Public Safety Crime Records Service, county governments, the Department of Health and Human Services, licensing and certification boards in any state I hold a certification or license. I hereby authorize Lavender Springs Residential Assisted Living to thoroughly investigate my references, work records, education, and other matters to m suitability for employment and authorize my current and former employers to disclose from the company any and all letters, reports, and other information pertaining to my employment with them, without giving me prior notice of such disclosure. In addition, I hereby release Lavender Springs Residential Assisted Living, my current and former employers, and all other persons, corporations, partnerships, and associations from any all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure.* This field is required.The background check includes: Employee Misconduct and/or Nurse Aide Registry, CMS OIG Exclusion list, Criminal History, sex offender registry, former and present employers references, and licensure and or certification credentials.
37
Additional Information for Background CheckThis information is optional and will only be used to assist in narrowing the results of the background check. Our hiring decisions will not in any way be influenced by this information.
Date of Birth
Race / Nationality
Gender
Other Possible Names
38
Criminal History AffidavitAs part of completing this application, you will be required to sign and agree to the following criminal history affidavit. Please review this agreement
39
I have read the Criminal History Affidavit and agree to sign this agreement as part of my potential employment with Lavender Springs.* This field is required.
40
My signature below certifies that I have read and understand this complete application, and agree to the terms and conditions outlined herein.* This field is required.
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