Application for Employment

Faribault Senior Living

843 Faribault Rd., Faribault, MN 55021
We are an equal opportunity employer, dedicated to a policy of non-discrimination on any basis including race, color, age, sex, religion, disability or national origin, consistent the Americans with Disabilities Act. Applicants may request accommodations needed to participate in the application process.
Legal Name*

PrefixFirst NameMiddle NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone No. (Home)*
Phone No. (Cell)
Have you ever applied for employment with us?*

YesNo
if yes, Month & Year:
Are you either a U.S. Citizen or an Alien authorized to work in the United States?*

YesNo
Social Security #
Employment Desired
Position:*
Date You Can Start:*

MonthDayYear
Date
Availability*

AMPMNightsFTPT
Apart from absence for religious observance, are you available for full time work?*

YesNo
If no, what hours?
Would you work overtime?*

YesNo

Educational Background*

	Name of Educational Institution	Location of Campus (City,State)	Major Course Of Study	Number of Years Attended	Diploma or Degree (Y/N)
High School
College/Tech
Trade, Business or Correspondence

Please list any skills you have that are appropriate for the position you are applying for:

Employment History

Starting with your PRESENT or MOST RECENT EMPLOYER list in consecutive order the past THREE employers.
If currently employed, may we contact your employer?

Current Employer / Previous Employer #1
Full Name of Company
Phone Number

Country CodeArea CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name & Title of Supervisor
Title of Your Position

Employment Dates & Wage/Salary

	Start	End
Employed From (Mo/Yr)
Salary $/hr or $/month

Reason for Leaving
List jobs held, duties performed, skills used, & promotions while employed at this company:

Previous Employer #2
Full Name of Company
Phone Number

Country CodeArea CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name & Title of Supervisor
Title of Your Position

Employment Dates & Wage/Salary

	Start	End
Employed From (Mo/Yr)
Salary $/hr or $/month

Reason for Leaving
List jobs held, duties performed, skills used, & promotions while employed at this company:

Previous Employer #3
Full Name of Company
Phone Number

Country CodeArea CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name & Title of Supervisor
Title of Your Position

Employment Dates & Wage/Salary

	Start	End
Employed From (Mo/Yr)
Salary $/hr or $/month

Reason for Leaving
List jobs held, duties performed, skills used, & promotions while employed at this company:

References

Please list the names and information of three persons not related to you, whom you have known for at least one year.

	Full Name	Phone Number	Years Acquainted
Reference #1
Reference #2
Reference #3

Emergency Contact
In case of an emergency notify:

First NameLast Name
Relation to applicant:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Do you have any physical limitations that preclude you from performing any work for which you are being considered?
If yes, what can be done to accommodate your limitations?

Authorization

Please read carefully:
If you are hired by this company, you will be required to attest to your identity and employment eligibility, and to resent documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements.

Authorization –

"I certify that the facts contained in this application and accompanying this resume, if any are true and complete to the best of my knowledge. I understand that any false statements, omission, or misrepresentation on this application is sufficient cause for refusal to hire or dismissal if I have been employed on matter when discovered by the company. I understand that my employment is conditional on a background check. I authorize the company to thoroughly investigate all statements contained in my application or resume and I authorize my former employers and references to disclose information regarding my former employment, character, and general reputation to the company without giving me prior notice of such disclosure. In addition, I release the company, any former employers and all references listed above from any and all claims, demands or liabilities arising our of or related to such investigation or disclosure. I understand and agree that if I am hired, my employment will be “at will” and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or the company. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the company unless made in writing. If hired, I agree to abide by all time company work rules, policies and procedures. The company retains the right to revise its policies or procedures, in whole or in part at any time."
Signature*
MonthDayYear
DateHourMinutesAM/PM Option
Should be Empty:

Faribault Senior Living

Employment Desired

Employment History

References

Emergency Contact

Authorization