Church Home LifeSpring Employment Application

Church Home LifeSpring Employment Application
Name of Employee*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
If hired, can you provide evidence of legal eligibility to work in the U.S.?*

YesNo
Any offer of employment is conditioned upon completing form I-9 and providing the appropriate documents for identity and work authorization.
Position Desired*
Wage/Salary Desired:
Select your desired work designation*

Memory Care Team - Full TimeMemory Care Team - Part TimeSkilled Nursing Team - Full TimeSkilled Nursing Team - Part Time
Upload Your Resume

Browse Files

Cancelof
When can you begin work?*

MonthDayYear
Date
Are you 18 years of age or older?*

YesNo
If under 18 years of age, you will be required to submit a birth certificate or work certificate as required bystate or federal law.

EDUCATIONAL HISTORY
Educational History
Name of High School attended*
City & State*
Did you graduate?*

YesNo
GED

YesNo
Name of College or Technical School
City & State
Did you graduate?

YesNo
Degree
Major
Are you presently enrolled in school?*

YesNo
If yes, give name and address of school and expected degree date
Name of College or Technical School
City & State
Did you graduate?

YesNo
Degree
Major
Are you presently enrolled in school?

YesNo
If yes, give name and address of school and expected degree date
List any job-related skills or accomplishments, including military service
- Your Availability For Work -

	From	To
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Total hours per week you are available to work*
Do you have any special requests or needs for a work schedule?

EMPLOYMENT HISTORY
-Provide Three References Who Are Not Former Employers Who We May Contact-

	Name and Occupation	How do you know them, and for how long?	Phone Number
Reference 1
Reference 2
Reference 3

Your Employment History

List names of employers with present or last employer listed first.
Employer 1
May we contact current employers before you are offered a position?*

YesNo
Name of Employer
Job Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Duties
Dates of Employment

From: To :
Hourly pay or salary

Starting pay:Ending pay:
Supervisor
Phone Number

Area CodePhone Number
Reason for Leaving
Employer 2
Name of Employer
Job Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Duties
Dates of Employment

From: To :
Hourly pay or salary

Starting pay:Ending pay:
Supervisor
Phone Number

Area CodePhone Number
Reason for Leaving
Employer 3
Name of Employer
Job Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Duties
Dates of Employment:

From: To :
Hourly pay or salary:

Starting pay:Ending pay:
Supervisor:
Phone Number

Area CodePhone Number
Reason for Leaving
ADDITIONAL INFORMATION: Please list any other information that you wish to have considered as a part of this application or that you feel would make you an asset to our facility.
EMERGENCY CONTACT*

First NameLast Name
Emergency Contact Phone #*

Area CodePhone Number
Emergency Contact Alternate Phone #

Area CodePhone Number

	Yes	No
Have you ever applied here for employment?
Have you been employed here previously?
Are you able to lift at least 50 lbs?
Have you been bonded?
Have you been refused a bond or had a bond cancelled?
Have you ever been convicted of a criminal offence involving dishonesty or breach of trust?

Please explain if you have ever been convicted of a criminal offense involving dishonesty or breach of trust

AUTHORIZATION
CAREFULLY READ EACH STATEMENT BEFORE SIGNING AT THE BOTTOM
I certify that all of the information provided in this employment application is true and complete to the best of my knowledge, and I authorize investigation of all statements contained in this application, including acriminal background and drug test, as applicable. I understand that any false or incomplete information may disqualify me from further consideration for employment and may result in my immediate discharge if discovered at a later date.

I understand and agree that if hired, I will abide by Church Home Rehabilitation & Healthcare, LLC's rules and regulations. I will participate and cooperate in all investigations including substance abuse tests upon request.

I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employer, past employers, and other organizations to provide information concerning my previous employment and other relevant information that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I further understand and agree that if hired, my employment will be AT-WILL for no definite term and maybe terminated at any time, with or without cause and with or without notice by me or Church Home Rehabilitation & Healthcare, LLC. If employed, I authorize Church Home Rehabilitation & Healthcare, LLC to supply information regarding my employment record to any government agency, or other party with a legal interest in such information and I hereby knowingly and voluntarily release Church Home from any and all liability for providing such information.

I have read, understand, and agree to the above statements.
Signature*

Clear
* Please use your cursor above to draw signature.
Should be Empty:

Church Home LifeSpring Employment Application

- Your Availability For Work -

-Provide Three References Who Are Not Former Employers Who We May Contact-

Your Employment History

CAREFULLY READ EACH STATEMENT BEFORE SIGNING AT THE BOTTOM