Application For Employment - ALC Property Services

Name (required):

Email (required):

Address (required):

Telephone(Home) (required):

Cell:

Work:

Position applied for:

FT:

PT:

Per Diem:

Days:

Evenings:

Nights:

Date available to start work (required):

Are you over the age of 18? (required)

YesNo

Have you applied to work with us before?

YesNo

If yes, when?

Are you willing to work an irregular schedule, weekends, overtime, holidays or different shifts if necessary?:

YesNo

If NO, Please Explain:

How did you hear about us?

Education

School Name / Address:

No. Years Completed:

Grad. Date:

Major / Degree:

EMPLOYMENT HISTORY

(List most recent employment first)

Dates:

Employer name / Telephone:

Position Held:

Salary/Wage:

Reason for leaving:

PROFESSIONAL REFERENCES

(Please provide three)

Name:

Address:

Telephone No.:

Email Address:

UNITED STATES MILITARY SERVICE

Branch:

Dates of service:

Rank at discharge:

Duties:

OTHER EXPERIENCE

Other relevant experience or qualifications:

BACKGROUND

Have you ever:

(i) Been found guilty of abusing, neglecting, exploiting or mistreating a nursing home resident by a court of law; or

(ii) Had a finding entered into the Vermont State Nurse Assistants Registry or the Vermont Adult Abuse Registry concerning abuse, neglect, exploitation or mistreatment of residents or misappropriation of their property?

(iii) Been convicted of a crime?

If YES, please explain:

Are you prevented from becoming lawfully employed in this country by your Visa or Immigration status? If YES, please explain:

Emergency contact:

Telephone No.:

Relationship to you:

CERTIFICATION AND AUTHORIZATION

Please read thoughtfully and carefully.

I certify that all facts I have stated in this Employment Application are true and complete and I acknowledge that Mertens House is relying on the accuracy of the information provided in making a hiring determination. I authorize Mertens House to verify the accuracy of the information provided herein, and I authorize former employers, educational institutions and credit agencies to release information concerning me to Mertens House. I also authorize Mertens House to give references and provide information about me in response to inquiries subsequent to my employment if I am hired. I understand that falsification, misrepresentation or omission of requested facts may result in denial of employment or, if I am employed by Mertens House, may result in immediate dismissal. I understand and agree that if I am hired, my employment will be for no definite period and may, regardless of the date of payment of wages, be terminated at any time without notice and with or without reason, by me or by Mertens House. I also understand and agree that no one has authority to promise me job security or continued employment except the Administrator at Mertens House in a formal written agreement signed by both of us.

Sign Here With Your Mouse:

Signature of Applicant (Sign Here With Your Mouse:)

Date