APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT
Which facility are you applying for?*
Admin Email
example@example.com
HR Email
example@example.com

Days and Hours Available
What date would you be able to begin work?*

MonthDayYear
Date
Salary Desired
Are you available to work overtime?*

YesNo
Schedule (choose all that apply)*

Full Time (32 hours or more a week)Part Time (less than 32 hours a week and minimum of 20 hours per week)PRN (on-call)
Shift (choose all that apply)

DayEveningNight

Day

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
From
To

Education

	Name and Location of School	Course of Study	Years Complete	Diploma or Degree Received
High School
College
Vocational or Trade School
Graduate Work

References
Please list three (3) professional references
Supervisor Name*
Supervisor Title*
Company*
Phone*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Fax Number
Please enter a valid fax number.
I request that employment information regarding me is released to this Company for potentially gaining a position as a Type a label* (insert job title).
Signature*

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By signing and filling out the above declaration and E-Signature I acknowledge and understand that they are intended for use across all 3 reference fields and associated forms and will be applied accordingly.
Supervisor Name
Supervisor Title
Company
Phone
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Fax Number
Please enter a valid phone number.
Supervisor Name
Supervisor Title
Company
Phone
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Fax Number
Please enter a valid fax number.

Previous Employment

Time Employed

	Name, Address, and Phone Number of Employer (List most recent)	Name and Title of Supervisor	Position Held and Rate of Pay	Reason for Leaving	Dates Employed: From: To:
1.
2.
3.
4.

Referral
How were you referred to us? (choose all that apply and explain in the space provided)

InternetEmployment/Unemployment AgencyWalk-InSchoolJob FairOther
Referral
Internet Site
Job Fair
Other (describe)
Disclaimer and Signature
I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.

I understand that employment may be conditioned upon successfully passing a medical examination and that I will be required to satisfactorily complete a drug screening as a condition of employment.

I hereby authorize persons such as schools, my current employer (if applicable), and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitabilit for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information

I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.
Signature*

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This application will not be considered active after 30 days.

Disclosure and Release of Information Authorization Investigative Consumer Report
For Your Information: As an applicant for employment or an employee, or volunteer you are a consumer with rights under the Fair Credit Reporting Act. When evaluating you for employment, promotion, reassignment, or retention as an employee, an investigative consumer report may be obtained from a consumer-reporting agency and may be obtained at any time during the application process or during your employment.

I authorize this facility/organization and HR Revolution, a consumer reporting agency, to obtain information from all personnel, educational institutions, government agencies, companies, corporations, credit reporting agencies, law enforcement agencies at the federal, state or county level, relating to my past activities, to supply any and all information concerning my background. This information may include, but is not limited to, academic, residential, achievement, previous employment verification and/or job performance, worker’s compensation, professional licenses, credit reports, driving history, and criminal history records.

I understand that an Investigative Consumer Report may be prepared summarizing this information. The report may include information obtained through personal interview regarding my character, general reputation, personal characteristics, and/or mode of living. I may also have the right to request additional disclosures regarding the nature and scope of the investigation, as well as a written summary of my rights under the FCRA. If requested, the consumer-reporting agency will explain the contents of my file. I understand that proper identification will be required and that I should direct my request to:

HR Revolution, 3750 Oakton, IL 60076. Phone 773-968-5315. Fax 866-972-0350.

I understand that by requesting this information, no promise of employment is being made. I also understand that a photocopy of this authorization be accepted with the same authority as the original; and that if employed by this facility/organization this authorization will remain in effect throughout such employment and in the event of reasonable suspicion, a new report may be obtained at any time during employment. I understand that the information requested below regarding date of birth, race and sex is for the sole purpose of gathering the above information accurately and will not be used to discriminate against me in violation of any law.
Please complete the following information:
Employee/Volunteer Signature*

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Please list any other names that you have been known by:
Social Security Number*
Please enter a valid Social Security number.
Sex*

MaleFemale
Race
Date of Birth (for identification purposes only)*

MonthDayYear
Please indicate all addresses (including state of residency) for the last (5) five years: Use back in necessary:
Current Street Address, City/State/Zip*

Street Address

Street Address Line 2

CityState

Zip Code
From*

MonthDayYear
Date
Previous Street Address, City/State/Zip*

Street Address

Street Address Line 2

CityState

Zip Code
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Previous Street Address, City/State/Zip

Street Address

Street Address Line 2

CityState

Zip Code
From

MonthDayYear
Date
To

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
From

MonthDayYear
Date
To

MonthDayYear
Date
If at any time, in another state where you didn’t reside, you have pending charges and/or you have been convicted of or pled guilty or no contest to a felony or misdemeanor, other than a minor traffic related infraction, please indicate below. Do not answer “yes” if an unresolved charge/conviction has been annulled, expunged, sealed, pardoned, erased, restricted, or impounded.*

YesNo

Policy Overview

At The Blossoms at Arkansas, we are committed to preventing resident abuse, neglect, mistreatment, and misappropriation of property. Every resident deserves care in a person-centered environment where they are treated with dignity and respect. As part of your application, you must understand and agree to support this policy.
1. Pre-Employment Screening: We do not hire individuals convicted of abuse, neglect, mistreatment, or theft. Background checks, including state registries and criminal records, are required before hiring.
2. Your Responsibility: You must report any suspected or observed abuse, neglect, or mistreatment immediately to a supervisor or the Administrator without fear of retaliation.
3. What Constitutes Abuse: Abuse includes physical, verbal, sexual, or mental harm, neglect, involuntary seclusion, and misappropriation of resident property.
4. Training: Comprehensive training on resident rights, abuse prevention, and reporting will be provided upon hire.
5. Reporting Process: Notify a supervisor or the Administrator immediately if abuse is suspected.
6. Separate the alleged perpetrator and ensure resident safety.
7. Document incidents as instructed during training.
8. Investigation: All allegations will be investigated promptly, and findings will be reported to the appropriate authorities.
By applying, you agree to uphold these standards. Violations may result in disciplinary action, including termination.
Signature*

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APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT

Applicant Information

Days and Hours Available

Education

References

Previous Employment

Referral

Disclaimer and Signature

Disclosure and Release of Information Authorization Investigative Consumer Report

Reference Check Authorization Form

Affirmative Action Program Announcements and Invitation to Self-Identify

Voluntary Self-Identification of Disability

Pre-Offer Invitation to Self-Identify Veteran Status