* = Required Information
APPLICATION FOR EMPLOYMENT
Personal Information

Present Address
Permanent Address
Yes No
Full Time Part Time Temp Seasonal
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Education
Academic
Current Attending
Yes No
Last Completed
Yes No
Current/Previous Employment
Date Month and Year
Name and Address of Employer
References: Give the names of three persons not related to you to whom you have known at least 1 year
List any foreign language(s) and check the box that best describes your skill level.
Read and Write Read and Speak Speak Only
Read and Write Read and Speak Speak Only
In Case of Emergency Notify
Initial Conditions of Employment – please read carefully

Reporting to work with impaired abilities or the possession, consumption or distribution of drugs or alcohol on company premises and/or worksites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant or employee to agree to physical examination, polygraph and/or substance testing, if required by the company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy will result in dismissal.

It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed. Furthermore, I understand that just as I am free to resign anytime, Assist the Living Resident Care Home reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of Assist the Living Resident Care Home has the authority to make any assurances to the contrary.

I give Assist the Living Resident Care Home the right to investigate all police, driving, and personal records and references, if job related. I hereby release from liability Assist the Living Resident Care Home and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

Assist the Living Resident Care Home is an Equal Opportunity Employer. Assist the Living Resident Care Home does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, State or Federal law.

Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation and failing settlement in mediation, to binding arbitration. Unless otherwise agreed a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company panel of mediators and will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section 1-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce.

This application is current for 60 days. At the conclusion of this time if I have not heard from Assist the Living Resident Care Home and still wish to be considered for employment, it will be necessary to fill out a new application.

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