Samaritan Village Employment Application

Full Name *

Today's Date *

Date

Physical Address *

City, State, Zip *

Mailing Address (if different than physical)

Mailing Address - City, State, Zip

Email Address *

example@example.com

Phone Number *

Do you have reliable transportation? *

Yes No

Are you 18 years of age or over? (minimum age requirement: 18 years) *

Yes No

Have you ever worked for Samaritan Village? *

Yes No

If yes, indicate name at time of previous employment

Do you have any relatives/friends working for Samaritan Village? *

Yes No

If yes, state name(s) and relationship

If hired, can you provide evidence of your legal right to live and work in this country? *

Yes No

Position *

Date available to start *

Date

Desired Hourly Rate or Salary *

Desired Employment Type *

Regular Full-Time Work (30+ hours per week) Regular Part-Time Work (20-30 hours per week) Per Diem/On-Call

Availability (check all that apply) *

AM (days) PM (nights) Overnight (NOC)

Availability (check all that apply) *

Monday-Friday Saturday Sunday Other

Are you able to perform the essential functions of the job for which you are applying? *

Yes No

High School (School Name and Location) *

Graduate *

Yes No

Degree / Diploma *

Yes No

College/University (Name and Location)

Graduate

Yes No

Degree / Diploma

Yes No

College/University II (Name and Location)

Graduate

Yes No

Degree / Diploma

Yes No

Vocational/Business School (School Name and Location)

Graduate

Yes No

Degree / Diploma

Yes No

Indicate any foreign languages you can speak, read, and/or write

Have you obtained any special skills or abilities as a result of service in the military?

Yes No

If yes, please describe

Do you have any other experience, training, qualifications, or skills that qualify you for this position or employment at Samaritan Village? Please describe.

List three individuals, not related to you, who have knowledge of your work performance within the last 5 years.

Name *

Reference #1

Occupation *

Reference #1

Number of years acquainted *

Reference #1

Phone Number *

Reference #1

Email Address

Reference #1

Name *

Reference #2

Occupation *

Reference #2

Number of years acquainted *

Reference #2

Phone Number *

Reference #2

Email Address

Reference #2

Name *

Reference #3

Occupation *

Reference #3

Number of years acquainted *

Reference #3

Phone Number *

Reference #3

Email Address

Reference #3

List all current and past employment starting with your most recent employer (last 10 years is sufficient). Account for all periods of unemployment. Include any job-related military service assignments and volunteer activities. You must complete this section even if attaching a resumé.

Employer #1 Name

May we contact for reference?

Employer Location (City, State, Country)

Employer email

example@example.com

Employer Phone Number

Job Title

Dates of Employment (from - to)

Supervisor’s Name & Title

Reason for leaving

Employer #2 Name

May we contact for reference?

Employer Location (City, State, Country)

Employer email

example@example.com

Employer Phone Number

Job Title

Dates of Employment (from - to)

Supervisor’s Name & Title

Reason for leaving

Employer #3 Name

May we contact for reference?

Employer Location (City, State, Country)

Employer email

example@example.com

Employer Phone Number

Job Title

Dates of Employment (from - to)

Supervisor’s Name & Title

Reason for leaving

Employer #4 Name

May we contact for reference?

Employer Location (City, State, Country)

Employer email

example@example.com

Employer Phone Number

Job Title

Dates of Employment (from - to)

Supervisor’s Name & Title

Reason for leaving

Please read carefully, initial next to each paragraph and sign below.

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances 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 of material fact on this application or on any document 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.

Initials

I hereby authorize Samaritan Village to thoroughly investigate my references, work records, education and other matters related to my suitability for employment and, further, authorize the and other references I have listed to disclose to the company any and all letters, reports, information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my 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.

Initials

I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s Chief Executive Officer or his designee.

Initials

Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien, or outstanding judgment) be conducted by internal personnel employed by the company, I am entitled to copies of any such public records obtained by the company unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box below.

I waive receipt of a copy of any public record described in the paragraph above.

Initials

We provide equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws, we prohibit discrimination and harassment of any type.

Upload Your Resume (optional)

Applicant’s Signature

Clear

Date

PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION, LICENSES, AND TRAINING

PROFESSIONAL REFERENCES

EMPLOYMENT HISTORY