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Embed code for: 01 Employee Application
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We consider applications for all positions without regard to race, color, religion, creed, sex, national origin, disability, sexual orientation, citizenship status or any other legally protected status.
Name: Application Date:
Email Address: ____________________________
Position(s) you are applying for:
How did you learn about us?
Are you over 18 years of age? ( Yes ( No
Have you ever filed an application with us before? ( Yes ( No
If yes, when?
Have you ever been employed with us before? ( Yes ( No
Do any of your friends or relatives, other than spouse, work here? ( Yes ( No
Are you currently employed? ( Yes ( No
May we contact your present employer? ( Yes ( No
Are you prevented from lawfully becoming employed because of
Visa or Immigration status? ( Yes ( No
When are you available: ( Full Time ( Part Time
Please check the boxes for the shifts you are able / want to work. Shifts are from 8 to 8 and we hire for both 12 and 24 hour shifts and morning help hours.
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Day ( ( ( ( ( ( (
Night ( ( ( ( ( ( (
Morning ( ( ( ( ( ( (
When would you be available to start?
Have you been employed at another residential assisted living facility?
( Yes ( No If yes, dates of employment:
State your reason(s) for leaving:
Have you ever been convicted of a crime? ( Yes ( No
If yes, please describe:
*Note: Colorado Regulations require that a criminal history check be done on all employees in the residential care setting.
EDUCATION RECORD SCHOOL CITY / STATE CIRCLE YEAR
COMPLETED High School 1 2 3 4 College 1 2 3 4 Other:
What diplomas, degrees or certificates have you been awarded?
Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or any other protected status.
Employer (w/ address and phone) Dates Employed
Reason for leaving:
Supervisor: May we contact? ( Yes ( No
Describe any specialized training, apprenticeship, skills and extra-curricular activities:
Describe any job-related training you’ve received:
Do you have any physical and/or mental conditions or disabilities which may limit your ability to perform the job description(s) for the position(s) you are applying for?
( Yes ( No
If yes, list the specific conditions/disabilities and specify how they would limit your ability to perform the job:
Do you have experience with any of the following (please check all that apply):
( Caring for others ( Caring for the elderly ( Cooking for large groups
( Dementia ( Cleaning ( Activity Development
( Leading music ( Playing cards/games ( Mental diagnoses
( Diabetes ( Parkinson’s ( Charting
( QMAP Cert. (Current) ( Medication Administration ( First Aid Cert (current)
( Menu development ( CPR Cert (current) ( Activities of Daily Living
( I understand that it will be necessary for me to complete a health questionnaire and/or to have a physical examination as required by state regulations prior to employment with this facility.
( I understand that all personnel must have screening for tuberculosis as a condition of employment in this residential care setting as required by state regulations.
( I understand that the facility must check my “criminal history” and my past employment record during the application process.
( I also understand that if employed, false statements on this application form may be considered cause for dismissal.
Applicant’s signature: _________________________________ Date: ______________________
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tly employed? ( Yes ( No
( Menu development ( CPR Cert (current) ( Ac