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

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.

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.

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.

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.

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.