Application for Employment

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General Information

Position Desired Date of Application
Name Email
Address
County Township / Burough
Have you been a resident of the Commonwealth of Pennsylvania for at least 2 years immediately proceeding the date of this application? Yes No (If no list the date of residency in PA)
Telephone No. Home Business
May we call you at work? Yes No Alternate Phone No.
Best time to call you at either: Home Business
Are you 18 years of age or over? Yes No
An offer of employment is contingent upon satisfactory proof of your authorization to work in the United States.
Are you legally eligible for employment in the United States? Yes No
Have you ever been convicted of an offense which involved abusing, neglecting, or mistreating individuals or a felony in a court of law or convicted through a court martial? Yes No
Do you have any history of violent crime, conviction for violent crime or have you ever been dismissed from employment due to abuse of residents or fellow employees? Yes No
All applicants are required, as a condition of employment, to have a criminal history report performed. Conviction of one or more of the crimes listed in the Older Adult Protective Services Act may result in a denial of employment
Do you have relatives employed at Garden Spot Village? Yes No
If yes, relationship of that person?
Position(s) applied for: 1. 2.
Minimum salary requirement: $
Status desired: Full time Part time Flex-pool Temporary
Shift desired: 1st 2nd 3rd other
If your application is considered favorable, on what date would you be available to begin employment?

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Education and Training

School	Name	Diploma Yes / No	Degree Yes / No
High School		Yes No	Yes No
College		Yes No	Yes No
College		Yes No	Yes No
Tech School		Yes No	Yes No
Other		Yes No	Yes No

Professional Licensure State Expiration Date
Certification/Registration State Expiration Date
Use this space to explain or comment on any section of the application or to describe any special training or
experience which qualifies you for work you wish to do.

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Referred By

Ad in newspaper or other publication (Name of Paper):
Friend: Walk-in: Other:

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EMPLOYMENT HISTORY

Employment: List present or last employer first
May we contact your present employer? Yes No
Employer: Address: Telephone:
Position: Dates of Employment: from Dates of Employment: to
Salary Supervisor
Duties
Reason for leaving or Desiring change

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Employer: Address: Telephone:
Position: Dates of Employment: from Dates of Employment: to
Salary Supervisor
Duties
Reason for leaving or Desiring change

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Employer: Address: Telephone:
Position: Dates of Employment: from Dates of Employment: to
Salary Supervisor
Duties
Reason for leaving or Desiring change

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Explain any gaps in work history
Have you ever been discharged or asked to resign from a job? Yes No
If yes, explain

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Other Information

MILITARY EXPERIENCE:
Have you served in the U.S. Armed Forces? Yes No If yes, what branch?
Dates of duty: From to Rank at separation
Briefly describe your duties
PERSONAL REFERENCES:

Name (No Relatives)		Address / Email Address / Telephone Number	Occupation
1.
2.
3.

PERSON TO BE NOTIFIED IN CASE OF EMERGENCY:
Name: Relationship: Home phone: Other phone:
Address:

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Final Step

Garden Spot Village is an equal opportunity employer and, in conformity with applicable laws, does not discriminate with regard to race, color, creed, national origin, ancestry, age, sex, handicap, disability, veteran status, or other status protected by law.

Please Note: Garden Spot Village is a Non-Smoking Campus.

READ CAREFULLY AND SIGN

I certify that facts given herein are true and complete to the best of my knowledge. I understand that any omission or false statements on this application or interviews shall be considered sufficient cause for rejection of my application or dismissal of my employment. I authorize and request the release of reference information from persons, employers, and /or school contacts by Garden Spot Village including investigation of all statements contained in this application as may be necessary in arriving at an employment decision. Garden Spot Village requires and employment shall be contingent upon passing a medical examination of the applicant selected for possible employment. Failure to submit to the physical examination will result in denial of employment. I understand that I am required to abide by all the rules and regulations of Garden Spot Village. I understand that no provision of the application, interviews, and/or other Garden Spot Village policies are intended to create an employment contract between Garden Spot Village and myself for either employment or the providing of any benefit. If an employment relationship is established, I understand that I have the right to terminate my employment at anytime and that Garden Spot Village retains a similar right.

I fully understand the terms and conditions of this document and agree to them in full.