The West Monroe Guest House - Online Employment Application

Application for Employment

PLEASE COMPLETE ALL SECTIONS, IF NOT APPLICABLE, ENTER N/A.

Personal Information

Last Name:*		First Name:*	Middle Name:
Email:*
Phone Number:*
Alternate Phone:
Street Address:*
City:*		State:*	Zip:*
Previous Address If Less Than Two Years:
Social Security No:*	(###-##-####)
Driver License Number:		State Issued:	Expiration Date:
Position Applying For:*	House Keeping Dietary LPN RN CNA Book Keeping Ward Clerk Other
Rate of Pay Expected:*
What type of employment you are seeking?*
If seeking part-time work, specify the number of days per week:
Date you can start work:*
Shift Preference:*
If Shift Preference is unavailable, will you work?:*	Day Evening Night
If required, will you work?:*	Saturdays Sundays Holidays Rotating Shifts
Are you either a U.S. Citizen or an Alien who has the legal right to work in the job(s) of which you are applying?*	Yes No
Are you 18 years of age or older?*	Yes No
Have you ever been convicted of a felony or misdemeanor other than minor traffic violation?*	Yes No
A felony conviction will not necessarily be a barrier to employment. To help us evaluate your application, please describe the nature of felony and your subsequent rehabilitation:

Have you ever been disciplined for resident abuse?*	Yes No
Have you ever been disciplined for child abuse?*	Yes No
Do you have relatives or friends employed at this company?*	Yes No
If yes, please enter the information.
Have you ever been employed by this company?*	Yes No
If yes, dates, position, and department employed.
Have you ever applied at this company before?*	Yes No
How did you hear about this position?*
Other Language You Speak:
Sign Language:	Yes No

Record Of Education

School attended: *
City: *
State: *
Zipcode: *
Course of Study: *
Last Grade Completed: *
Degree: *

Additional Education (+)

Professional Licenses and/or certifications

If not applicable type N/A
Are you currently licensed (Please Select One): *
Registration	Licensed No.	Certification No.
Has your license ever been denied, revoked, or suspended?*	Yes No
If yes, please explain?

If Licensed, Registered or Certified*

If not applicable type N/A
Type	No.	State Issued	Date Issued.	Expiration

Employment History If background employment records are in any other surname, please show name used:

List entire employment history, starting with your present employer. Please explain in detail any gaps in employment, showing dates and reasons.

Company Name: *

Phone: *

Address: *

Address 2:

City: *

State: *

Zipcode: *

Supervisor's Name: *

Supervisor's Phone: *

Job Title: *

Employed From: *

To: *

Last Pay Rate: *

Duties: *

Reason for leaving: *

Additional Employment (+)

References
List two (2) people (no relatives) you have worked with and whom we may contact for a reference.

First Reference

Name:*

Street:*

City:*

State:*

Zip:*

Email Address:*

Second Reference

Name:*

Street:*

City:*

State:*

Zip:*

Email Address:*

RECORD INFORMATION RELEASE To Whom It May Concern:

I have applied to "The West Monroe Guest House" for employment. To enable "The West Monroe Guest House" to properly evaluate my qualifications, I request and authorize you to release and furnish to "The West Monroe Guest House" any and all information in your records or files, or within your knowledge, concerning my present and/or past employment with you.

I authorize all persons, schools, current employer, previous employers, and organizations named in this application or provided by me to the facility to provide this facility with any relevant information that may be requested by the facility. I also hereby release all parties seeking and providing information from any and all liability or claims for damages whatsoever that may result from this information's release, disclosure, maintenance, or use.

Signature Date: 22-Feb-12 Signature(Full Name):* Social Security:* (###-##-####)

Company Name:

In consideration of my employment I agree to conform to all of the rules and regulations of this facility and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either this facility or myself. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by this facility. I understand that no representative of this facility, other than its Administrator, has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing and it must be express and in writing.

I certify that I have read and understand the foregoing paragraphs. I further certify that all the information submitted by me on the application is true and complete to the best of my knowledge, and I understand that any false information, omissions, or misrepresentations of facts called for on this application may be cause for the denial of my application or, if I am employed, discharged at any time.

As a condition of employment, I hereby consent to testing for drug and alcohol use, as determined to be appropriate by management, either before being hired or at any time during my employment with this facility.

Application Date: 22-Feb-12

Signature (Full Name):*