Magnolia Estates, Winder, GA
APPLICATION FOR EMPLOYMENT
Applicants receive consideration for employment without regard to race, national origin, creed or religion, sex, marital status, age, or disability. We encourage the employment of veterans or our U.S. Armed Forces, Job applications will be considered active for a period of two months. If you wish to be considered for employment after two months, you must reapply. Please read and complete all sections carefully. False statements on this application shall be considered sufficient cause for rejection during the hiring process or termination.
GENERAL INFORMATION
Today's Date
Name	LAST NAME		FIRST NAME		MIDDLE NAME
Social Security Number
E-mail
Telephone			Message Telephone
Current Address:	STREET			CITY
	STATE	ZIP	Years at this address
Previous Address:	STREET			CITY
	STATE	ZIP	Years at this address
Have you been convicted of a felony or an offense involving drugs/narcotics, theft, or inflicting bodily injury?					Yes	No
If yes, explain fully:
Have you ever been excluded from participating in a Federally funded program?					Yes	No
Are you currently the focus of an investigation which could result in exclusion from Federally funded programs?					Yes	No
If yes to either of the above questions, explain fully:
If your former employment, education, or military service are under a name other than indicated above, please list:
If under 18, do you have a work permit?				Yes	No	N/A
Do you have a legal right to work in the U.S.?				Yes	No
If not a U.S. citizen, enter your Alien Registration Number:
Have you ever been bonded?		Yes	No	If Yes, where?
How were you referred to us?
List any friends or relatives working here:
Have you worked for this facility before?		Yes	No	If Yes, when?
Position held:   Reason for Leaving:
Do you have any commitments to another employer which might affect your employment with us?					Yes	No
If yes, explainf fully?
WORK DESIRED
Scheduling: Each nursing facility must be adequately staffed 7 days a week, 24 hours a day to maintain quality patient care. Work schedules are varied and require some flexibility. Please consider carefully all of your personal time commitments when responsing.
Position desired:	FIRST CHOICE		SECOND CHOICE		THIRD CHOICE
Date you can start work:				Expected pay rate:
Shift Preference:	1st Shift		2nd Shift		3rd Shift
Can you rotate shifts?	Yes	No
	Full Time		Part Time   (Hours per week: )
	Temp.   (from:   to )

WORK HISTORY
List your present or most recent employer first. Include military service if among your last four jobs. Give dates of employment if applicable. (You may list volunteer experience if you do not have paid work experience with four employers. For volunteer work, write "V" in the salary field.)
1	Employer				Telephone
	Address
	Dates Employed				Job Title
	Salary		Supervisor's Name / Job Title
	Reason for Leaving
2	Employer				Telephone
	Address
	Dates Employed				Job Title
	Salary		Supervisor's Name / Job Title
	Reason for Leaving
3	Employer				Telephone
	Address
	Dates Employed				Job Title
	Salary		Supervisor's Name / Job Title
	Reason for Leaving
4	Employer				Telephone
	Address
	Dates Employed				Job Title
	Salary		Supervisor's Name / Job Title
	Reason for Leaving
	All References may be checked, including my present employer.
	All References may be checked, except
EDUCATION
High School
Address
Course of Study				Last Year Completed: 1   2   3   4
Did you graduate?		Yes   No		List Diploma or Degree:
College
Address
Course of Study				Last Year Completed: 1   2   3   4
Did you graduate?		Yes   No		List Diploma or Degree:
Other School
Address
Course of Study				Last Year Completed: 1   2   3   4
Did you graduate?		Yes   No		List Diploma or Degree:

LICENSURE
Complete this section if the position for which you are applying requires a license, certification, or registration of any kind.
TYPE OF LICENSE		STATE	LIC. NUMBER		EXPIRATION DATE
TYPE OF LICENSE		STATE	LIC. NUMBER		EXPIRATION DATE
TYPE OF LICENSE		STATE	LIC. NUMBER		EXPIRATION DATE
If you do not have the required license, have you applied?					Yes	No
If exam is required, give the scheduled date:
If not licensed in this State, have you applied for reciprocity?					Yes	No
ADDITIONAL INFORMATION
Please give us any additional information you feel would be useful to us (including honors received, volunteer or community services, special qualifications, memberships in professional organizations, or other information you feel is related to your application for employment).
Please Read Carefully
I AGREE	I certify that the information contained in this application is correct to the best of my knowledge. I understand that falsification of this information is grounds for refusal to hire or, if hired, dismissal.
I AGREE	Except as noted otherwise, I authorize any individuals or organizations listed as references in this application to give you any and all information concerning my previous employment, character and general reputation, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties from all liability from any damages which may result from furnishing such information to you. I authorize you to request and receive such information.
I AGREE	I understand that it is important that I am at work when scheduled and therefore I am responsible for making necessary transportation arrangements to ensure that I am at work on time and as scheduled.
I AGREE	In the interest of the safety and health of our residents and employees, employment is subject to a successful health screening and/or physical if required by law or dictated by the physical demands of the specific job.
I AGREE	I understand that no representative of the institution has any authority to enter into any agreement for employment for any specified period of time. I also understand that if hired I will have entered into my employment voluntarily and that I will be free to resign at any time for any reason or no reason. Similarly, the employer may terminate the employment relationship at any time for any reason or no reason.
I AGREE	I agree to conform to the employer's drugs in the workplace policy and agree to submit to drug tests as required by the employer.
I AGREE	In connection with my application for employment with Magnolia Estates Assisted Living, I understand that investigative background inquiries are to be made on myself, which could include consumer, criminal, driving, former employment, and other reports. These reports will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment from previous employers. Further, I understand that you will request information from various Federal, State, and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil, and other experiences, as well as claims involving me in the fields of insurance comapnies. I authorize, without reservation, any party or agency contacted by Magnolia Estates Assisted Living to furnish the above-mentioned information. I consent to your obtaining the above information.
I AGREE	I am NOT under the influence of illegal drugs or alcohol.
I AGREE	I have NEVER been dismissed from any employment for abuse to clients/residents.
I AGREE	I have NEVER been convicted of a crime.

© 2007 Magnolia Estates