Caregiver Job Application Assured Senior Living

AN EQUAL OPPORTUNITY EMPLOYER APPLICATION FOR EMPLOYMENT

PRE-EMPLOYMENT QUALIFICATIONS
Todays Date

MonthDayYear
Date
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*

I attest under penalty of perjury that I am (choose best option)*

A citizen or national of the United StatesAn alien lawfully admitted for permanent residenceAn alien authorized by the Immigration and National Service to work in the United States
Sign Application:
By Submitting this Application I certify: * That the information submitted in this application is complete, true and correct.* You have not knowingly withheld any requested information or any information that might adversely affect your chances for employment.* You, the undersigned applicant, have personally completed this application.* You understand that if any misrepresentation is found, or the results of the investigations are not satisfactory, any offer of employment may be withdrawn, and that if you are already employed your employment will be terminated immediately. You also authorize Assured Senior Living and/or its designated agents and representatives to conduct a comprehensive review of your background that may include, but is not limited to: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records*

I AcceptI Don't Accept
Enter your full name below to sign the application (E-signature)*

Criminal Background and History Investigation Waiver

In accordance with Chapter VII for Residential Care Facilities in Colorado, any staff employee who has direct personal contact with residents of a facility shall be of good moral and responsible character.

In making such determination, Assured Senior Living may have access to and shall obtain any criminal history record information from a criminal agency, subject to restrictions imposed by such agency, and verify social security number and birth date for any person responsible for the care and welfare of residents in Lighthouse Assisted Living's homes.
Social Security Number (Please provide us a copy)*
Driver's License State*
Driver's License Number (Please provide us a copy of a photo ID)*
Birth Date*

MonthDayYear
Name*

First NameMiddle NameLast Name
Other Names Used
Prior Addresses in Last five Years*
List other states and counties of prior employment*
By affixing my signature below, I grant permission to Assured Senior Living to conduct an investigation into my background, confirm my social security identification and birth date, and call my references and former employers for purposes of this application.
Enter your full name below to sign the background check (E-signature)*
Current Date

MonthDayYear
Date
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