APPLICANT INFORMATION

Community *

Employee First Name *

Employee Last Name *

Phone Number *

Date of Birth *

Employee Email Address *

Address *

SS # *

Position Applying *

Availability *

Desired Shift *

Available Start Date * +

EMPLOYMENT HISTORY

Employer Name *

Phone Number *

Supervisor *

Address *

May we contact? *

Wage *

Position/ Title *

Start Date * +

End Date * +

Employer Name

Phone Number

Supervisor

Address

May we contact?

Wage

Position/ Title

Start Date +

End Date +

Employer Name

Phone Number

Supervisor

Address

May we contact?

Wage

Position/ Title

Start Date +

End Date +

EDUCATION

High School *

Did you graduate? *

If No, Years Completed

College/ University

Did you graduate? *

Degree/ Field of Study

Business/ Technical

Did you graduate? *

Field of Study

Additional

Did you graduate? *

Field of Study

Other Specialized Training Program(s)

REFERENCES

Name *

Phone Number *

Years Known *

Occupation/ Company *

Relationship *

Name *

Phone Number *

Years Known *

Occupation/ Company *

Relationship *

QUESTIONNAIRE

Have you ever been convicted of a felony? *

Yes

No

Do you consent to undergo a background check? *

Yes

No

Do you consent to being drug tested? *

Yes

No

Are you a citizen or authorized to work in of the USA? *

Yes

No

Are you able to perform the necessary functions of the position? *

Yes

No

Accommodations *

With

Without

How did you hear about Aspen Creek Senior Living? *

Additional Information

DISCLAIMER & SIGNATURE

As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresnted or omitted any facts, and are subsequently hired, you may be discharged from your position. You may be required to supply proof of authorization to work in the United States, undergo a drug test, and submit a background check.

Equal Opportunity Employer

While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race, sex for planning and reporting purposes only. This information is optional and failure to provide it will have no affect on your application for employment.

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Applicant Signature *

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