HILLCREST Employment Application

Hillcrest Living

Employment Application
Todays Date

MonthDayYear
Date
Your Name*

First NameMiddle NameLast Name
List any names you have used (Enter in as follows: Name1, Name2, ect) :
Your Birthdate*

MonthDayYear
Date
Gender at Birth

MaleFemale
Your Email
example@example.com
Your Phone Number*
Please enter a valid phone number.
Driver's License
Social Security Number (###-##-####)*
Current Address*

Street Address

County

CityState

Zip Code
Permanent Street Address *

Street Address

Street Address Line 2

CityState

Zip Code

Best Time to contact you

Hour Minutes

AM/PM Option
Availability and Position
Position Applying for*
Full-Time, Part-Time, PRN*
Number of Hours Desired Per Week
Desired Shift
Date available to Start

MonthDayYear
Date
Required Salary
Have you worked here before?

YesNo
If "Yes", select when

MonthDayYear
Date
Have you worked here before?

YesNo
If "Yes", select when

MonthDayYear
Date
Do you have a record of founded child or dependent adult abuse?*

YesNo
Are you a U.S. Citizen or a resident Alien legally authorized to work in the United States?*

YesNo

Professional Licenses and Certifications
Type
Date Aquired

MonthDayYear
Date
Number
State aquired from
Has your License or registration ever been suspended, revoked, or on probation?
Education
Name of High School
Did you graduate?
Name of College Attended
Major
Did you Graduate?
Other Educational Background

Employment History
Company Name #1
Phone Number
Please enter a valid phone number.
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Ending Title
Ending Salary
Reason for Leaving
Company Name #2
Phone Number
Please enter a valid phone number.
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Ending Title
Ending Salary
Reason for Leaving
Company Name #3
Phone Number
Please enter a valid phone number.
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Ending Title
Ending Salary
Reason for Leaving
Company Name #4
Phone Number
Please enter a valid phone number.
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Ending Title
Ending Salary
Reason for Leaving

References
Reference 1 Name
Reference 1 --How Do you know?
Reference 1 Phone Number
Please enter a valid phone number.
Reference 1 Email
Reference 2 Name
Reference 2 How Do You Know?
Reference 2 Phone Number
Please enter a valid phone number.
Reference 2 Email
Reference 3 Name
Reference 3 How Do you know?
Reference 3 Phone Number
Please enter a valid phone number.
Reference 3 Email

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

I understand that my employment is at-will and 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 sentance, except for a written agreement signed by the Administrator.

If I am hired, I agree to and authorize the use of direct deposit for payment of wages.

If I am hired, I agree to report any instance to Hillcrest Home, Inc. if I am convicted of a criminal offense, founded case of dependant adult abuse, a license or certification relevant to my duties has been revoked, or I am excluded from participation in the Medicare, Medicaid, or any other Federal health care program.

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

I hereby affirm that the information provided on this application (and accompanying resume, if applicable) 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 if discovered at a later date.
Signature

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Criminal History Record Check and Authorization for Release of Child and Dependant Adult Abuse Information
Criminal History Record Check Release Authorization:

I hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the Division of Criminal Investigation (DCI). Any criminal history data concerning me that is maintained by the DCI may be released by law. I understand this can include information concerning deferred judgements and arrests without dispositions.

Authorization for Release of Child and Dependant Adult Abuse Information:

I understand that my signature authorizes the requester to receive information to verify whether I am named on the Child Abuse or Dependant Adult Abuse Registry as having abused a child (Iowa Code section 235A.15) or dependant adult (Iowa Code section 235B.6). To the best of my knowledge, the information contained in Section 1 of this form is correct.

For further information on either of these releases, please contact the facility.
Criminal History Check*

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Authorization for Release of Child and Dependant Adult Abuse Information Signature*

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Hillcrest Living

Availability and Position

Professional Licenses and Certifications

Education

Employment History

References

Criminal History Record Check and Authorization for Release of Child and Dependant Adult Abuse Information