Elm Meadows Employment Application

First Name

Middle Name

Last Name

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

City

State

Zip Code

Social Security Number

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Position Applying For

Available Start Date

Date

Previously Applied

Previously Applied - If yes, when?

Employment Type

Other

Are you legally eligible to work in the U.S.?

If not North Carolina, what state?

Have you ever worked for this company?

Have you ever worked for this company? - If yes, when?

Days Available

Shifts Available

Transportation Responsibility Acknowledgment You are expected to maintain reliable transportation and arrive on time for all scheduled shifts. Please acknowledge that you understand this is your personal responsibility and an essential part of maintaining dependable employment at Elm Meadows Senior Living.

Initial Here

Are you able to perform the essential functions of the position, with or without reasonable accommodation?

If no, please explain

Have you ever been convicted, pled guilty or no-contest or have a pending case to a Criminal Offense? (excluding traffic citations)

If yes, please explain

Education

Professional Licenses or Certifications (e.g., CNA, RN, CPR), N/A if none

Education

Highest Degree Earned

Additional Training or Post Graduate Work (Institution Name, Location, Specific training), N/A if none

Company 1

Position 1

Dates of Employment 1

Supervisor Name 1

Supervisor Phone Number 1

Please enter a valid phone number.Format: (000) 000-0000.

Reason for Leaving 1

Company 2

Position 2

Dates of Employment 2

Supervisor Phone Number 2

Please enter a valid phone number.Format: (000) 000-0000.

Reason for Leaving 2

Company 3

Position 3

Dates of Employment 3

Supervisor Name 3

Supervisor Phone Number 3

Please enter a valid phone number.Format: (000) 000-0000.

Reason for Leaving 3

Reference 1 Name

First NameMiddle NameLast Name

Reference 1 Relationship

Reference 1 Phone

Please enter a valid phone number.Format: (000) 000-0000.

Reference 1 Email

example@example.com

Reference 2 Name

First NameMiddle NameLast Name

Reference 2 Relationship

Reference 2 Email

example@example.com

Reference 3 Name

First NameMiddle NameLast Name

Reference 3 Relationship

Reference 3 Phone

Please enter a valid phone number.Format: (000) 000-0000.

Reference 3 Email

example@example.com

I certify that the information provided in this application is true, complete, and correct to the best of my knowledge. I understand that any false or misleading information provided, or omission of relevant information, may disqualify me from further consideration for employment and may be grounds for termination if discovered at a later date.

I authorize Elm Meadows Senior Living to investigate all statements contained in this application and to contact any references or previous employers for verification. I release Elm Meadows Senior Living, its agents, and any individuals or organizations contacted from any and all liability that may arise from providing or obtaining suchinformation.I understand that submission of this application does not guarantee an interview or offer of employment. If hired, I agree to abide by all company policies, procedures, and guidelines.

I acknowledge that employment with Elm Meadows Senior Living is “at-will,” meaning either the company or I may terminate employment at any time, with or without cause or notice, unless otherwise stated in a written agreement signed by the Administrator or authorized representative.

I further understand that Elm Meadows Senior Living reserves the right to require drug screening, a criminal background check, and a two-step tuberculosis (TB) screening as conditions of employment. Refusal to comply with these requirements may result in disqualification from employment consideration or termination.

By signing below, I confirm that I have read and fully understand the above Applicant’s Statement.

Printed Name

Signature

Date

Elm Meadows Employment Application

Applicant Information

Education

Employment History

References

Applicant Statement