Application For Employment

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Education

EMPLOYMENT HISTORY

(List most recent employment first)

PROFESSIONAL REFERENCES

(Please provide three)

UNITED STATES MILITARY SERVICE

OTHER EXPERIENCE

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?

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.