HOME ABOUT US CARE CONTACT US Personal Information Last name * First name * Middle name * Email * Phone * Street address * City * State * Zip * # of years here * If you’ve been at your current address less than 5 years, please provide your previous address. Street Address City State Zip # of Years Here If under the age of 16, do you have a work permit? YesNo If you are not a U.S. citizen, do you have the right to remain permanently and work in the U.S.? YesNo Alien regulation #: Have you ever been convicted of a crime? *YesNo (Note: Conviction of a criminal oﬀense will not necessarily preclude your employment) If yes, describe in FULL detail: Employment Desired Position applying for* Wage desired * Shift you can work * 123 Schedule * Full timePart timeTemp How did you learn of this opening?* Date you can start * Have you ever worked for this company before? YesNo If yes, when? Supervisor Reason for leaving Education Highest grade completed?* 9th10th11th12th1yr College2yrs College3yrs College4+yrs College Name and location of last school attended* Date you left Name of vocational or trade training Extracurricular activities while in school Professional organizations membership, honors received, volunteer or community service or other qualifications you have which you feel are related to the position for which you are applying for ** ANY APPLICANT FOR EMPLOYMENT WHO WILFULLY FURNISHES, SUPPLIES OR OTHERWISE GIVES FALSE INFORMATION ON AN EMPLOYMENT APPLICATION THAT IS THE BASIS FOR A CRIMINAL HISTORY RECORD CHECK UNDER THIS SECTION SHALL BE GUILTY OF A CLASS A1 MISDEMEANOR. [NCGS 131E-265(e)] References List three persons whom you have known for at least a year. Do not include relatives. Name Best contact time AMPM Phone# Address Years known Name Best contact time AMPM Phone# Address Years known Name Best contact time AMPM Phone# Address Years known FORMER EMPLOYERS List below your work experience, starting with your last place of employment. Employer name Address Start date End date Name of supervisor Phone # Years known Employer name Address Start date End date Name of supervisor Phone # Years known Employer name Address Start date End date Name of supervisor Phone # Years known Employer name Address Start date End date Name of supervisor Phone # Years known May we contact your present employer at this time?* YesNo Employment Understanding (Please Read and Acknowledge THIS INSTITUTE DOES NOT DISCRIMINATE IN HIRING OR ANY OTHER DECISION ON THE BASIS OF RACE, COLOR, SEX, CITIZENSHIP, NATIONAL ORIGIN, ANCESTRY, VIETNAM ERA, VETERAN STATUS AND/OR ON THE BASIS OF AGE OR PHYSICAL OR MENTAL DISABILITY UNRELATED TO THE ABILITY TO PERFORM THE WORK REQUIRED. NO QUESTION ON THIS APPLICATION IS INTENDED TO SECURE INFORMATION TO BE USED FOR SUCH DISCRIMINATION. I VOLUNTARILY GIVE THIS INSTITUTION THE RIGHT TO MAKE A THOROUGH INVESTIGATION OF MY PAST EMPLOYMENT AND ACTIVITIES. I AGREE TO COOPERATE IN SUCH INVESTIGATION AND RELEASE FROM ALL LIABILITY OR RESPONSIBILITY ALL PERSONS, COMPANIES, OR CORPORATIONS SUPPLYING SUCH INFORMATION. I UNDERSTAND THAT MY EMPLOYMENT IS AT WILL, AND THAT EITHER PARTY IS FREE TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME WITHOUT CAUSE. I ALSO UNDERSTAND THAT MY EMPLOYMENT MAY BE TERMINATED FOR ANY MISSTATEMENT OR OMISSION OF FACT APPEARING ON THIS APPLICATION FORM. IF EMPLOYED, I WILL BE REQUIRED TO COMPLETE AN EMPLOYMENT VERIFICATION FORM (I-9), AND WITHIN THREE DAYS SHOW SATISFACTORY EVIDENCE OF IDENTITY AND ELIGIBILITY FOR EMPLOYMENT. I understand and accept the information above HOME ABOUT US CARE CONTACT US Interested in senior living, check out our sister facility, Clapp's Mountain Top Living for senior apartments. Built by MMOVentures © 2021 Clapp's Mountain Top Living