Evergreen Commons Employment Application
(Fields noted with an * are required) |
| Date |
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| Position Applied For |
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| Hours Available |
Full-time Part-time |
| Name* |
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| Address* |
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| Email |
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| Phone* |
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| U.S. Citizen |
Yes No |
| U.S. Military Service |
Yes No |
| Under 18 years of age? Do you have a work permit? |
Yes No |
Have you worked for
Evergreen Commons / Eden Park before? |
Yes No |
| If Yes, where and when? |
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| How did you hear about Evergreen Commons? |
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| Can you perform the essential functions of the position for which you are applying? |
Yes No |
| If no, please explain |
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EDUCATION |
| (Select Highest Grade Completed) |
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HIGH SCHOOL |
| Name and Location |
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| # Of Yrs. Attended |
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| Did You Graduate? |
Yes No |
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NURSING SCHOOL |
| Name and Location |
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| # Of Yrs. Attended |
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| Did You Graduate? |
Yes No |
| Major Subject |
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COLLEGE |
| Name and Location |
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| # Of Yrs. Attended |
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| Did You Graduate? |
Yes No |
| Major Subject |
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| License, Vocational or Trade Trainings: |
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WORK EXPERIENCE
(Please list most recent position first. Provide complete name and address for each employer.) |
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EMPLOYER 1 |
| Name |
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| Address |
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| Phone |
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| Salary |
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| Period of Employment From |
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| To |
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| Supervisor's Name |
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| Job Title |
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| Reason For Leaving |
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EMPLOYER 2 |
| Name |
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| Address |
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| Phone |
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| Salary |
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| Period of Employment From |
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| To |
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| Supervisor's Name |
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| Job Title |
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| Reason For Leaving |
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EMPLOYER 3 |
| Name |
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| Address |
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| Phone |
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| Salary |
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| Period of Employment From |
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| To |
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| Supervisor's Name |
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| Job Title |
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| Reason For Leaving |
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| Please Explain Any Gaps in Employment |
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LICENSED PERSONNEL |
| STATE REGISTRATION NUMBER |
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| EXPIRATION DATE |
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| IF NO LICENSE, PERMIT NUMBER |
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| IS YOUR PROFESSIONAL LICENSE NOW, OR WAS IT EVER, UNDER PROBATION OR RESTRICTIONS OR ANY OTHER LIMITATIONS? |
Yes No |
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REFERENCES |
| Name |
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| Address |
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| Phone |
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| Name |
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| Address |
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| Phone |
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| Name |
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| Address |
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| Phone |
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| Have you ever been convicted of any crime or other offense other than a traffic violation? |
Yes No |
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If so, please describe fully the criminal conviction(s), listing the nature of the offense, your age at the time of the offense, and your rehabilitation since the conviction(s). A conviction will not necessarily be a bar to employment.
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AGREEMENT - Please read and select the appropriate button below:
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I understand that any employment will be on a six (6) month introductory basis and that my employment may be terminated with or without cause or notice, at any time, at either my option or that of the Company. I understand that no management representative has any authority to enter into any agreement for continuing employment for any specific period of time or which is contrary to the foregoing without written approval of the Company. I give the Company permission to contact all or any of my previous employers, references and any investigative agency including credit or criminal background check and authorize them to provide all information requested of them by the Company. I understand that I may be required to have a pre-employment drug test. I release all parties giving or receiving information from any liability associated with doing so. After a tentative offer of employment has been made, if requested by the Company, I agree to take a job-related medical examination at no personal expense and authorize the examining physician to disclose the findings to the Company. I understand that any offer of employment is conditioned upon receipt of satisfactory references and satisfactory completion of such job-related medical examination.
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| I have provided truthful and complete responses to all inquiries in the application and understand that the discovery of any falsification or omission constitutes a ground for immediate dismissal. If employed, I will abide by the Company’s rules and regulations, which I understand are subject to change by the Company. |
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